Temperamental and character profiles of preschool children with ODD, ADHD, and anxiety disorders

Abstract

Background

The aim of the present research was to identify profiles of Cloninger's temperament and character dimensions associated with anxiety disorders, oppositional defiant disorder (ODD) and attention- deficit/hyperactive disorder (ADHD) in preschoolers.

Method

The parents of 120 children (mean age = 4.65 years; S.D. = .88) completed the Preschool Temperament and Character Inventory (PsTCI). The sample consisted of 4 groups (n = 30 per group): ADHD, anxious, ODD and control children. To diagnose the different disorders, the Preschool Age Psychiatric Assessment and Child Behavior Checklist 1.5-5 was administered to the parents.

Results

The discriminant analysis showed that three temperamental dimensions (Harm Avoidance, Novelty Seeking and Persistence) enabled the correct classification of 75% of cases within their own group, which demonstrated an adequate accuracy rate. The ADHD children showed a temperamental profile that was characterized by high Novelty Seeking, low Reward Dependence and low Persistence, while the anxious children obtained high scores in Harm Avoidance. The profiles of the ODD children shared some common features (high Novelty Seeking) with the ADHD children, but the ODD children were characterized by higher Persistence and Harm Avoidance compared with ADHD children.

Conclusions

The present results indicate that Cloninger's temperamental dimensions allow to differentiate the three most frequent psychiatric disorders in preschoolers.

Introduction

Temperamental dimensions have a dual role that consists of predictive factors for the onset of psychopathology and as the basis for a better understanding of future developmental trajectories [1], [2], [3]. The temperamental predisposition to emotional–behavioral regulation problems has long been considered a risk factor by many authors [4], [5]. Empirical evidence suggests that several disorders, including ADHD (attention deficit hyperactive disorder), ODD (oppositional defiant disorder) and anxiety disorders, are often characterized by affective temperamental traits, such as negative emotionality, that moderate the relationship between emotional self-regulation and both positive and negative outcomes [6], [7]. Regarding ADHD, studies of adults suggest a genetic, neuropsychological and neuroanatomical parallel between ADHD and specific temperamental and personality traits, such as low Conscientiousness, low Agreeableness, and high Neuroticism [8], [9], [10], [11], [12].

Recently, the integration of dimensional models with a categorical approach in developmental research and early onset psychopathology has become more frequent and important than in the past, as demonstrated in the relevant scientific literature [2], [13]. In particular, Korean studies on school-age children with ADHD, based on Cloninger's psycho-social model, highlight a personality profile that is characterized by high Novelty Seeking [14], [15] and low Self-Directedness in both the parents' and children's self-ratings. Moreover, using a wide sample of school-age children and adolescents with ADHD, it has been established that the dimensional model can explain the heterogeneity of the disorder better than categorical criteria [16]. There are also important contributions in the literature regarding anxiety disorders and temperamental profiles. In adults with social anxiety, high Harm Avoidance, low Novelty Seeking and low Self-Directedness have been reported [17]. Research on children and adolescents (6–17 years old) with social phobia has reached similar conclusions, including high Harm Avoidance and low Self-Directedness [18].

Most developmental research concerns school-age children and adolescents, but less is known about the temperamental characteristics of pre-school children that show early onset psychiatric disorders; these early clinical conditions can be considered real disorders, whether they are only beginning to emerge or previously existing [19], [20], [21], [22]. It is noteworthy that research on the temperament of preschool age with early onset psychopathology remains controversial and requires further analyses [22].

Some studies on preschoolers have demonstrated a relationship between externalizing behaviors and disorders (mainly ADHD) significantly associated with difficult temperament [23], [24], extraversion [25] and disinhibition [3]. Research highlights the frequent association between preschoolers with anxiety disorders and behavioral inhibition [26], [27], [28], low adaptability/approachability [23], and difficult temperament [24], [29]. Interesting contributions have also originated from studies on ODD, which strongly represents a disorder associated with temperamental risk factors [30], [31]. ODD is an early onset disorder associated to an increased risk of secondary internalizing and externalizing disorders in older children and adolescents [32], [33], [34]. Single ODD dimensions (i.e. irritability, oppositional behavior) predicts psychiatric disorders at follow-up [35], [36], but in this latter field findings are not coherent [37]. ODD core traits, such as oppositional behavior and negative emotionality, are considered measures of temperamental domains [38], [39]. Negative emotionality in ODD predicts both externalizing and internalizing disorders, unlike impulsivity and activity, which are only associated with externalizing disorders [40]. Similar findings have been demonstrated in community based studies: the temperamental trait of negative emotionality is a strong predictor of the association between ODD and internalizing disorders, whereas the temperamental trait of activity is a strong predictor of the association between ODD and ADHD [2]. These results suggest that individual temperamental differences that are evident in the preschool years may provide even earlier distinguishing markers for diverging internalizing or externalizing disorder pathways [41].

This brief review of the existing literature highlights the importance of studying temperamental traits; however, the overall picture of the temperamental differences in preschool children with early onset psychopathology remains unclear. Thus, it should be noted that most clinical studies are difficult to compare because temperament is measured in several ways. In addition, diagnoses are often not comparable due to the fact that different rating scales are used rather than basing all diagnoses on structured interviews and DSM criteria.

The aim of our research was to identify the dimensional temperament and character profiles that can significantly discriminate the three most frequent psychiatric disorders in preschoolers: anxiety disorders, ODD, and ADHD. Differently from most previous work on temperament and psychopathology that examines multiple bivariate associations, in the present study we adopted a multivariate approach that simultaneously utilizes multiple personality traits to discriminate different psychiatric disorders in preschoolers. In particular, we tested the ability of the temperamental and character dimensions measured by Cloninger's bio-psycho-social model [42], [43], [44] to distinguish preschoolers diagnosed as anxious, ODD, or ADHD. In the theoretical framework developed by Cloninger and co-workers, normal and maladaptive personality development is the result of a self-organizing multidimensional dynamic system created by complex genetic and environmental interactions [45].

Cloninger first developed a model of temperament based on heritable differences in the way behavior is conditioned by patterns of reward and punishment that elicit basic emotional responses like fear or anger. The temperament model was based on studies of the effects of genetics and neuropsychological data on behavioral learning [42], [45], which led to the identification of four dimensions of temperament related to inhibition of behavior by signals of punishment or non-reward (i.e. Harm Avoidance), activation of approach behavior by novelty (i.e., Novelty Seeking), activation of social attachment (i.e. Reward Dependence), and maintenance of behavior despite frustration (i.e., Persistence). The temperament dimensions measure the associatively conditioned aspects of personality that are not rational or self-aware but are moderately stable throughout life [46]. Cloninger next developed a model of mental self-government of these temperament traits by higher cognitive processes he called Self-directedness (the executive aspect of self-government), Cooperativeness (the legislative aspect of self-government), and Self-transcendence (the judicial aspect of self-government) [43]. These traits integrate much earlier work in humanistic and transpersonal psychology [43], [44]. These character traits can be measured in pre-schoolers [47] but mature with age in the direction of culturally sanctioned norms [46].

Cloninger's model has been shown to be a useful model for discriminating different psychiatric disorders in adults [17], [48], as well as in adolescents [18], [49], [50] and school age children [14], [15], [51], [52]. To diagnose the different disorders in preschool children, we administered a reliable structured interview, the Preschool Age Psychiatric Assessment (PAPA) [53], which provides a comprehensive assessment of DSM-IV-TR diagnoses.

We describe our initial hypothesis as follows. We expected preschoolers with ADHD and anxiety disorders to show temperament and character configurations similar to older children. More specifically, we expected higher Novelty Seeking and lower Cooperativeness scores in the ADHD children, and higher Harm Avoidance associated with low Self-Directedness scores in the anxious children. The literature does not contain distinctions in terms of the temperamental profiles between ODD and ADHD. However, because ODD criteria combines both emotional and behavioral symptoms, in contrast to ADHD, we suggest that the ODD profile may like children with ADHD but also high in Harm Avoidance like children with anxiety disorders.