Numerous empirical studies have provided data suggesting that disruptive behavior disorders such as oppositional

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1 Disruptive Behavior in Preschool Children: Distinguishing Normal Misbehavior from Markers of Current and Later Ji S. Hong, MD, Rebecca Tillman, MS, and Joan L. Luby, MD Objectives To investigate which disruptive behaviors in preschool were normative and transient vs markers of conduct disorder, as well as which disruptive behaviors predicted the persistence of conduct disorder into school age. Study design Data from a longitudinal study of preschool children were used to investigate disruptive behaviors. Caregivers of preschoolers ages years (n = 273) were interviewed using the Preschool Age Psychiatric Assessment to derive the following diagnostic groups: conduct disorder, externalizing disorder without conduct disorder, internalizing disorder without externalizing disorder, and healthy. At school age, participants were again assessed via an age-appropriate diagnostic interview. Logistic and linear regression with pairwise group comparisons was used to investigate clinical markers of preschool conduct disorder and predictors of school age conduct disorder. Results Losing one s temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing in the preschool period were found in both healthy and disordered groups. In contrast, high-intensity argument/defiant behavior, both low- and high-intensity aggression to people/animals, high-intensity destruction of property, high-intensity deceitfulness/stealing, and high-intensity peer problems were markers of preschool conduct disorder and predictors of school age conduct disorder. Inappropriate sexual behavior was not a marker for preschool conduct disorder but was a predictor of school age conduct disorder. Conclusion These findings provide a guide for primary care clinicians to help identify preschoolers with clinical conduct disorder and those who are at risk for persistent conduct disorder in childhood. Preschoolers displaying these symptoms should be targeted for mental health assessment. (J Pediatr 2015;-:---). Numerous empirical studies have provided data suggesting that disruptive behavior disorders such as oppositional defiant disorder (ODD) and conduct disorder can be identified in early childhood. 1-9 In preschool populations, disruptive behavior is one of the most common reasons for referral to a mental health clinic. 1 The estimated prevalence of preschool ODD and conduct disorder ranges from 4% to 16.6%, and 3.9% to 6.6%, respectively. 2-4 Despite ongoing efforts to define, describe, and validate these disorders and to differentiate clinically significant conduct problems from normative developmental extremes, ambiguity about this distinction persists Keenan et al 5-8 investigated the reliability and discriminant and predictive validity of preschool ODD and conduct disorder. They studied preschoolers from psychiatric and pediatric clinics using the Kiddie-Disruptive Behavior Disorder Schedule. Both ODD and conduct disorder symptoms were found at greater rates in the clinical sample with symptom severity correlated with functional impairment. When participants were re-evaluated 3 years later, a diagnosis of ODD and conduct disorder at baseline substantially increased the risk for later diagnosis of these disorders with ORs of and 15.55, respectively. Notably, at the 3-year follow-up, 82% of participants with ODD at baseline and 61% with conduct disorder at baseline met the criteria for ODD and conduct disorder. The Environmental Risk Longitudinal Twin Study followed 2232 children from birth to age 10. 2,9 Relative to the comparison group, 5-year-olds with conduct disorder self-reported more antisocial behaviors on a puppet interview, displayed more disruptive behaviors during an observation, as well as numerous cognitive impairments and psychosocial risks. Those with conduct disorder at age 5 had more educational difficulties and a 20-fold increased risk of diagnosis of conduct disorder at age 7 years. At the age 10 years follow-up, diagnosis of conduct disorder at age 5 years predicted increased risk for attention CAPA DSM-IV EXTL w/o conduct disorder INTL w/o EXTL MDD ODD PAPA Child and Adolescent Psychiatric Assessment Diagnostic and Statistical Manual of Mental Disorders, 4th Edition Externalizing disorder without conduct disorder Internalizing disorder without externalizing disorder Major depressive disorder Oppositional defiant disorder Preschool Age Psychiatric Assessment From the Department of Psychiatry, Washington University School of Medicine, St. Louis, MO Supported by the National Institute of Mental Health (R [to J.L.]). The authors declare no conflicts of interest /$ - see front matter. Copyright ª 2015 Elsevier Inc. All rights reserved. 1

2 THE JOURNAL OF PEDIATRICS Vol. -, No.- deficit-hyperactivity disorder, aggression, and delinquency as well as emotional and educational impairments. These findings suggest that the diagnosis of conduct disorder in early childhood is a robust marker of risk for persistent disruptive psychopathology and poor outcomes in later childhood. However, this study did not inform which early childhood disruptive behaviors were the most specific predictors of later childhood conduct disorder, an important issue, because disruptive behaviors during the preschool period may be common normative extremes. To address bias and confounds related to parental report, Wakschlag et al developed a behavior observation schedule and a companion parent rating scale to assess more objectively and comprehensively preschool disruptive behaviors. Using a dimensional approach to quantify disruptive behaviors, they found that preschool disruptive behaviors had 4 distinctive domains: temper loss, noncompliance, aggression, and low concern for others. Temper loss and noncompliance ranged from mild/normative to severe and clinically significant. Aggression and low concern for others were observed in a small proportion of children and represented the severe, clinically significant end of the spectrum. Despite these compelling data, ambiguity remains about how to distinguish normative developmental extremes from clinically significant phenomena, as well as which early childhood disruptive behaviors predict the persistence of conduct disorder into later childhood. The ability to distinguish children in need of early interventions from those who will simply grow out of their misbehaviors is a critical public health issue. Our study aimed to address this gap in the literature by investigating which preschool disruptive behaviors were normative vs markers of preschool conduct disorder and which behaviors predicted the persistence of conduct disorder into school age. Given the limited guidelines and available screening scales to identify preschool disruptive behaviors, these data may be critical to guide the identification of children in need of intervention in primary care. 16 Methods Preschoolers between 3 and 5.11 years of age were recruited from multiple sites throughout the greater metropolitan St. Louis area for participation in the Preschool Depression Study. Recruitment was done through primary care practices and preschools/daycares in an effort to increase the diversity of the final sample. Participants were screened via a validated checklist to identify those with symptoms of major depressive disorder (MDD) or other psychiatric disorders, and healthy controls. 17 Children with chronic illness, marked speech and language or other developmental delays, and/or neurologic disorders or autism spectrum disorder were excluded. Full details of the study recruitment process and subject flow have been described in detail by Luby et al. 18 From the total baseline sample of (n = 306), 273 had complete data on the variables of interest for the current study. Participants were categorized into the following mutually exclusive diagnostic groups based on the Preschool Age Psychiatric Assessment (PAPA) 19 : conduct disorder, externalizing disorder without conduct disorder (EXTL w/o conduct disorder), internalizing disorder without externalizing disorder (INTL w/o EXTL), and healthy. Participants with conduct disorder before age 6 were included in the preschool conduct disorder group. Participants without conduct disorder before age 6 who had attention deficit-hyperactivity disorder or ODD before age 6 were included in the EXTL w/o conduct disorder group. Participants without an externalizing disorder before age 6 who had MDD, generalized anxiety disorder, separation anxiety disorder, or posttraumatic stress disorder before the age of 6 were included in the INTL w/o EXTL group. Finally, participants without an Axis I diagnosis before age 6 were included in the healthy group. Participants who had conduct disorder between the ages of 6.0 and 9.11 years based on the PAPA or the Child and Adolescent Psychiatric Assessment (CAPA) were categorized as the school age conduct disorder group. Study participants and their primary caregivers participated in up to 7 comprehensive annual assessments that spanned from preschool into school age, conducted at the Early Emotional Development Program at the Washington University School of Medicine between 2003 and All study procedures were approved by the Washington University School of Medicine institutional research board and consent/assent were obtained from all participants. At baseline, dyads participated in a 3- to 4-hour laboratory assessment, during which primary caregivers (94% mothers) were interviewed about their children s behaviors, emotions, and age-adjusted manifestations of psychiatric symptoms using the PAPA. The PAPA parent report was used before age 8.0 years, the CAPA parent report was used when participants were years, and the CAPA parent and child report were used when participants were 9.0 years old or older. Raters trained to reliability and blind to the subject s diagnostic status from previous waves administered the PAPA/CAPA at each assessment point. All interviews were audiotaped, and methods to maintain reliability and prevent drift, which included ongoing calibration of interviews by master raters for 20% of each interviewer s cases, were performed in consultation with an experienced clinician (J.L.) at each study wave. The PAPA is an interviewer-based, caregiver-reported diagnostic assessment with established test-retest reliability designed for use with primary caregivers of children aged 2-6 years (but its use up to age 8 years has been established), which includes all relevant Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) criteria and their age-appropriate manifestations. 4,19,20 The PAPA conduct section covers all DSM-IV criteria for ODD and conduct disorder. To evaluate conduct problems, the PAPA conduct section and peer problem section were used. Most of the conduct items measure intensity, frequency, and duration. The CAPA is an interviewer-based, child/adolescent, or caregiver-reported diagnostic assessment (from which the PAPA was derived) with established test-retest reliability designed for use with children and adolescents aged years, which includes all relevant DSM-IV criteria 2 Hong, Tillman, and Luby

3 ORIGINAL ARTICLES and their age-appropriate manifestations. 21,22 The PAPA and CAPA used DSM-IV based computer algorithms to generate diagnoses, including conduct disorder diagnosis. A diagnosis was made counting all symptoms within each diagnosis category. Statistical Analyses There are 59 items in the PAPA conduct section and peer problem section, and we categorized them into 13 symptom clusters on the basis of DSM-IV definition and subtypes using data derived from the PAPA: losing temper cluster, argument/defiant behavior-low intensity cluster, argument/ defiant behavior-high intensity cluster, vindictiveness cluster, aggression to people/animals-low intensity cluster, aggression to people/animals-high intensity cluster, inappropriate sexual behavior cluster, destruction of property-low intensity cluster, destruction of property-high intensity cluster, deceitfulness/stealing-low intensity cluster, deceitfulness/ stealing-high intensity cluster, peer problem-low intensity cluster, and peer problem-high intensity cluster. Table I (available at details the PAPA items included in each symptom cluster. The symptom cluster score was the total number of items endorsed within the specified cluster. Preschool symptom clusters were compared between preschool diagnostic groups by the use of linear regression for continuous variables and logistic regression for dichotomous variables. Pairwise group comparisons were made via contrast statements. Logistic regression was used to determine whether preschool symptom clusters were significantly associated with schoolage conduct disorder. Demographic characteristics that differed between the conduct disorder and comparison group, psychotropic medication use during the follow-up, and preschool MDD were included as covariates in these models. All analyses were conducted with SAS v9.3 (SAS Institute, Cary, North Carolina). Bonferroni correction was used to account for multiple comparisons. Results There were 273 participants who had at least one assessment during both the preschool ( years) and school age periods ( years) and were therefore included in the analyses. There were 86 children with 1 preschool assessment, Table II. Characteristics of the sample (N = 273) School-age conduct disorder (n = 36) No school-age conduct disorder (n = 237) Mean SD Mean SD P value Baseline age, y Income to needs ratio % n % n c 2 P value Sex Male Female Race White African-American Other Family income #$ $ $ $ $ >$ Parental education High school diploma Some college year college degree Graduate education Parental Axis I disorder Yes No History of abuse/neglect Yes No Intact family Yes No Psychotropic medication during follow-up Yes No Preschool MDD Yes No c 2 Disruptive Behavior in Preschool Children: Distinguishing Normal Misbehavior from Markers of Current and Later 3

4 THE JOURNAL OF PEDIATRICS Vol. -, No children with 2 preschool assessments, and 74 children with 3 preschool assessments. There were 38 children with 1 school-age assessment, 153 children with 2 school-age assessments, and 82 children with 3 school-age assessments. The mean age of the children at the preschool assessments was years, and the mean age of the children at the school-age assessments was years. Table II compares characteristics of the sample in children who had a school-age conduct disorder diagnosis and those who did not. Compared with children without school-age conduct disorder, children with school-age conduct disorder were older at baseline and more likely to be nonwhite. Children with school-age conduct disorder also had lower income to needs ratios, more history of abuse/neglect, were less likely to come from an intact family, had more exposure to psychotropic medications, and were more likely to have a diagnosis of MDD during preschool period. Table III provides descriptive statistics for the preschool symptom clusters in the 4 preschool diagnostic groups and results of the group comparisons. There were no group differences in losing temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing. The following symptom clusters were significantly greater in the conduct disorder group than the other 3 groups: high-intensity argument/defiant behavior, both low- and high-intensity aggression to people/animals, high-intensity destruction of property, and high-intensity peer problems. Vindictiveness and high-intensity deceitfulness/stealing were greater in the conduct disorder group than in the INTL w/o EXTL group and the healthy group but were not significantly different from the EXTL w/o conduct disorder group. Of note, inappropriate sexual behavior was significantly greater in the conduct disorder group than in the healthy group (P <.0001) but was not significantly different in the conduct disorder group compared with the EXTL w/o conduct disorder and INTL w/o EXTL groups after Bonferroni correction (P =.0023 and P =.0012, respectively). The nonsignificant findings were likely attributable to low power, because of the relatively small size of the EXTL w/o conduct disorder and INTL w/o EXTL groups and the low rate of inappropriate sexual behavior. Only 1 subject with inappropriate sexual behavior had a history of sexual abuse in the preschool period. This subject was in the EXTL w/o conduct disorder group. Of the baseline 273 participants, 36 had a school-age conduct disorder diagnosis. The Figure illustrates the relationship between preschool symptom clusters and school-age conduct disorder diagnosis, when we adjusted for baseline age, income to needs ratio, race, history of abuse/neglect, family intactness, psychotropic medication use, and preschool MDD. High-intensity argument/ defiant behavior, both low- and high-intensity aggression to people/animals, inappropriate sexual behavior, high-intensity destruction of property, high-intensity deceitfulness/stealing, and high-intensity peer problems were significant predictors of school-age conduct disorder. Discussion The first aim in our study was to investigate which misbehaviors were normative and common among preschool children. Losing one s temper, low-intensity destruction of property, and low-intensity deceitfulness/stealing emerged as common misbehaviors that did not serve as markers of clinical disruptive disorders. Wakschlag et al 14,15 also found that temper loss was a common misbehavior in preschoolers but that it ranged from normative problems to clinically significant levels. In a previous analysis from the same study sample, 23 we found that the disruptive, depressive, and healthy groups differed in temper tantrum characteristics by frequency and severity, as well as the characteristics of behavior and Table III. Preschool symptom cluster scores by preschool diagnostic group Conduct disorder (n = 46) EXTL w/o conduct disorder (n = 57) INTL w/o EXTL (n = 62) Healthy (n = 106) Mean SD Mean SD Mean SD Mean SD P value Losing temper* 93.5% N = % N = % N = % N = Argument/defiant behavior-low intensity <.0001 Argument/defiant behavior-high intensity 2.85,z,x ,z <.0001 Vindictiveness* 84.8%,z N = % N = % N = % N = 37 <.0001 Aggression to people/animals-low intensity 2.50,z,x <.0001 Aggression to people/animals-high intensity 1.78,z,x <.0001 Inappropriate sexual behavior* 31.1% N = % N = 1 4.8% N = 3 2.9% N = 3 <.0001 Destruction of property-low intensity Destruction of property-high intensity 0.59,z,x <.0001 Deceitfulness/stealing-low intensity Deceitfulness/stealing-high intensity 2.48,z <.0001 Peer problems-low intensity <.0001 Peer problems-high intensity 0.78,z,x <.0001 Bonferroni-corrected P < *Percentages and numbers are given instead of means and SDs for dichotomous variables. Significantly greater than healthy. zsignificantly greater than INTL w/o EXTL. xsignificantly greater than EXTL w/o conduct disorder. 4 Hong, Tillman, and Luby

5 ORIGINAL ARTICLES print & web 4C=FPO Figure. Preschool symptom cluster scores as predictors of school-age conduct disorder. Bonferroni corrected * P <.0038; ** P < recovery patterns. Previous findings have also empirically established that tantrum behaviors among preschoolers can range from normative misbehavior to clinically significant levels. 23 Related to this, we aimed to identify behaviors that were outside the normal range and served as markers of clinically significant conduct disorder during the preschool period. High-intensity argument/defiant behavior, low- and high-intensity aggression to people/animals, high-intensity destruction of property, and high-intensity peer problems occurred significantly more frequently in the preschool conduct disorder group than the other 3 comparison groups (which included groups with other forms of psychopathology). Vindictiveness and high-intensity deceitfulness/stealing occurred more frequently in the conduct disorder group than in the internalizing group and healthy groups. Wakschlag et al 14,15 reported that aggression was found in a small portion of preschoolers and represented the abnormal end of the spectrum. Consistent with this reporting, our study indicates that both low- and high-intensity aggressive Table IV. Important behavioral markers in the preschool period Normative preschool misbehaviors Behaviorial markers of preschool conduct disorder Behavioral markers predicting school-age conduct disorder High-intensity argument/defiant behavior High-intensity argument/defiant behavior Low- and high-intensity aggression to people/animals Low- and high-intensity aggression to people/animals Low-intensity destruction of property High-intensity destruction of property High-intensity destruction of property High-intensity peer problems High- intensity peer problems Low-intensity deceitfulness/stealing High-intensity deceitfulness/stealing High-intensity deceitfulness/stealing Losing temper Vindictiveness Inappropriate sexual behavior Operational definition of each symptom cluster was described in Table I. Disruptive Behavior in Preschool Children: Distinguishing Normal Misbehavior from Markers of Current and Later 5

6 THE JOURNAL OF PEDIATRICS Vol. -, No.- behaviors are markers of conduct disorder in the preschool period. These findings suggest that primary care clinicians should assess the intensity of disruptive behaviors to determine which young children are in need of further mental health evaluation. The second aim was to investigate preschool behavioral markers that could serve as predictors of the persistence of conduct disorder into school age. We found that high-intensity argument/defiant behavior, both low- and high-intensity aggression to people/animals, inappropriate sexual behavior, high-intensity destruction of property, high-intensity deceitfulness/stealing, and high-intensity peer problems predicted school-age conduct disorder. Notably, all conduct disorder behaviors evident during the preschool period predicted school-age conduct disorder with the exception of vindictiveness. Another exception was that inappropriate sexual behaviors were not specific to conduct disorder in the preschool period, but predicted school-age conduct disorder. However, the null finding at preschool may have been due to the relatively small size of the comparison groups and the low rate of inappropriate sexual behavior. Stringaris and Goodman 24 found that 5- to 16-year-old children and adolescents who displayed headstrong behavior (argument/defiance) had a greater likelihood of having conduct disorder and antisocial behavior at a 3-year follow-up. In addition, hurtful behavior (vindictiveness) predicted aggressive offenses 3 years later. Our study findings suggested that high-intensity argument/defiance during the preschool period predicted school-age conduct disorder but vindictiveness did not. Rolon-Arroyo et al 25 found in an externalizing preschool sample that fighting, destruction of property, and stealing independently predicted later conduct disorder symptoms. In agreement with this, we found that both low- and high-intensity aggression, high-intensity destruction of property, and high-intensity deceitfulness/stealing predicted school-age conduct disorder. Consistent with our finding of inappropriate sexual behavior predicting school age conduct disorder, Gray et al 26 found in a cross-sectional study of 6- to 12-year old children with inappropriate sexual behaviors that 96% had at least one psychiatric disorder and 76% met the criteria of conduct disorder. Our finding demonstrates that inappropriate sexual behavior in the preschool period is a robust risk factor for school age conduct disorder. Gray et al 26 also reported that sexual touching (80%), fondling (72%), and sexual statements (60%) were the most common inappropriate sexual behaviors at age 6-12 years. These behaviors overlapped with the definition of inappropriate sexual behaviors in the PAPA: touching someone s private parts without consent, forcing other child to remove clothes, rubbing up against other child in a sexual way without consent, and making sexual comments toward others. Although Stringaris and Goodman 24 and Rolon-Arroyo et al 25 examined predictors of conduct symptoms, they did not investigate categorical DSM-IV definitions of conduct disorder, a clinically relevant outcome that was examined in the current study. We found other risk factors for school age conduct disorder, such as inappropriate sexual behavior and high-intensity peer problems. Inappropriate sexual behaviors were not well investigated in previous studies or were even excluded from preschool conduct disorder criteria. 5,6,15,25 In our sample, inappropriate sexual behavior was reported in 31% of the preschool conduct disorder group and notably it emerged as an important early behavioral marker for school-age conduct disorder. The current study differentiated between low-intensity and high-intensity misbehaviors based on severity levels in the PAPA conduct disorder module, a distinction that was not reported in other studies. We also found well-established demographic risk factors for conduct disorder, including poverty, child abuse/neglect, and nonintact family structure The school-age conduct disorder group had more exposure to psychotropic medications, which likely indicates that those with school-age conduct disorder had more impairing symptoms prompting medication treatment. A limitation of the current study was the sole reliance on parental report to establish diagnoses previous to age 9 years as well as the small sample size of children with conduct disorder at school age. This study would have been strengthened by the inclusion of other informants, such as teachers or daycare providers as well as observational measures. Another limitation is that we reported school-age outcomes but do not yet have data on preadolescent/adolescent outcomes, a period of high risk for conduct disorder. The original purpose of the research was to investigate preschool depression, and all data were derived from a sample that was oversampled for depressive symptoms, which may limit the generalizability of the findings. Therefore, an important next step would be to study larger samples and include multiple informants and methods to evaluate preschool disruptive behaviors and to follow participants through adolescence and early adulthood. Conduct disorder has been associated with very poor outcomes and high risk for later major psychiatric disorders, and childhood-onset conduct disorder is well known to have a persistent course and poorer prognosis than adolescent onset conduct disorder Currently, there are several evidencebased psychosocial treatments for early childhood disruptive behaviors and childhood-onset conduct disorder Considering the burden of childhood-onset conduct disorder as well as the availability of effective early interventions, identifying conduct disorder in the preschool period and referring individuals for early intervention is an important public health opportunity. Our study findings provide information on the key behavioral markers of preschool conduct disorder and behavioral markers predicting school age conduct disorder. These findings may provide a useful guide to primary care clinicians to identify and refer young children at risk of developing persistent childhood conduct disorder and other psychiatric disorders (Table IV). n Submitted for publication May 14, 2014; last revision received Oct 31, 2014; accepted Nov 18, Hong, Tillman, and Luby

7 ORIGINAL ARTICLES Reprint requests: Ji S. Hong, MD, Department of Psychiatry, Washington University School of Medicine, Campus Box 8134, 660 South Euclid Ave., St. Louis, MO References 1. Bufferd SJ, Dougherty LR, Carlson GA, Rose S, Klein DN. Psychiatric disorders in preschoolers: continuity from ages 3 to 6. Am J Psychiatry 2012;169: Kim-Cohen J, Arseneault L, Newcombe R, Adams F, Bolton H, Cant L, et al. Five-year predictive validity of DSM-IV conduct disorder research diagnosis in 4(1/2)-5-year-old children. Eur Child Adolesc Psychiatry 2009;18: Lavigne JV, Gibbons RD, Christoffel KK, Arend R, Rosenbaum D, Binns H, et al. Prevalence rates and correlates of psychiatric disorders among preschool children. J Am Acad Child Adolesc Psychiatry 1996; 35: Egger HL, Erkanli A, Keeler G, Potts E, Walter BK, Angold A. Test-Retest Reliability of the Preschool Age Psychiatric Assessment (PAPA). 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9 ORIGINAL ARTICLES Table I. Symptom clusters Symptom clusters Losing temper cluster Argument/defiant behavior-low intensity cluster Argument/defiant behavior-high intensity cluster Vindictiveness cluster Aggression to people/animals-low intensity cluster Aggression to people/animals-high intensity cluster Inappropriate sexual behavior cluster Destruction of property-low intensity cluster Destruction of property-high intensity cluster Deceitfulness/stealing-low intensity cluster Deceitfulness/stealing-high intensity cluster Peer problem-low intensity cluster Peer problem-high intensity cluster PAPA items included in cluster Losing temper Arguments with adults without physical violence by child Arguments with peers without physical violence by child Rule breaking in $2 activities Disobedience in $2 activities Defiance Wandering off at least once Annoying behavior in $2 activities Teasing in $2 activities Arguments with adults with physical violence by child Arguments with peers with physical violence by child Rule breaking in most activities Disobedience in most activities Wandering off for $15 minutes, difficult to find Annoying behavior in most activities Teasing in most activities Spiteful or vindictive Bullying using threats only Fights not resulting in physical injury Cruelty to animals not resulting in obvious injury Cruelty to people not resulting in physical injury Shoving not resulting in physical injury Isolated pinching causing pain Hitting not resulting in physical injury Kicking not resulting in physical injury Biting not resulting in physical injury Choking not resulting in physical injury Attack with a weapon not resulting in physical injury Bullying with actual violence Fights resulting in physical injury Cruelty to animals resulting in obvious injury Cruelty to people resulting in physical injury Shoving resulting in physical injury Repeated pinching resulting in physical injury Hitting resulting in physical injury Kicking resulting in physical injury Biting resulting in physical injury Choking resulting in physical injury Attack with a weapon resulting in physical injury Asked to leave daycare/school for fighting Asked to leave daycare/school for assault Inappropriate sexual touching (touching someone s private parts without consent, forcing other child to remove clothes, or rubbing up against other child in a sexual way without consent) Inappropriate sexual talk (sexual comments to others) Nondestructive vandalism Plays with matches, no supervision Destructive vandalism Deliberate setting of fires Making up a story that is not for a gain Cheating occurs in $2 activities Lying to escape punishment in $2 activities Cheating occurs in most activities Blaming (lying that results in others being blamed for the child s misdemeanor) Stealing Difficulty sharing in $2 activities Difficulty making friends, but maintained a friendship >3 months Conflictual relationship with at least one friend Difficulty sharing in most activities Difficulty making friends, with no friendship lasting >3 months Most or all friendships are conflictual Disruptive Behavior in Preschool Children: Distinguishing Normal Misbehavior from Markers of Current and Later 8.e1