The American Academy of Pediatrics (AAP) released new guidelines for diagnosing and treating attention deficit hyperactivity disorder (ADHD) in preschoolers as young as 4. Previous guidelines, issued in 2000 and 2001, focused on children aged 6 to 12, but the new recommendations expand the targeted age group to 4 to 18 to include both preschoolers and older teens.
The reason for the expanded advice? New data released in the past decade has revealed that ADHD can begin earlier, and that children may benefit from behavioral treatments before they enter school, where attention problems can impede learning.
“Treating children at a young age is important, because when we can identify them earlier and provide appropriate treatment, we can increase their chances of succeeding in school,” said Dr. Mark Wolraich, chair of the AAP subcommittee responsible for writing the report.
Kids with ADHD typically have problems focusing and paying attention. They are hyperactive and behave impulsively. But the condition may look different in different age groups. Among school-aged children (age 6 or older), about half don’t have issues with hyperactivity, according to Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Cohen Children’s Medical Center of New York, who specializes in studying preschool ADHD. In this age group, attention problems are more common, likely because they become more obvious in the school setting, where children need to sit in class and concentrate for longer periods of time.
Hyperactivity is more common among preschoolers, however. They may be accident-prone or have trouble playing with other kids. According to the AAP, it’s the number of symptoms, and the number of different caregivers who notice them, that is important. It’s not enough, for example, for only parents to complain of their child’s overactive behavior. In order to meet the bar for diagnosis and justify treatment, at least one other party, such as a day care teacher or babysitter, must also note the same behaviors. And these symptoms must be persistent and severe enough to impair the child’s ability to function, which could involve anything from their inability to get along with other children to being consistently unable to follow directions.
The new advice is similar to that in the diagnostic manual for diagnosing adult mental health disorders, and the AAP is advising pediatricians to follow the same guidelines in diagnosing the disorder among youngsters. It gives doctors something to look for in preschoolers, which may help parents and pediatricians to know when their child’s energetic activity is normal, and when it crosses the line to become ADHD.
As far as treatments go, the Academy is recommending that preschoolers under age 6 start with behavioral therapies first, and to consider medications such as methylphenidate (known as Ritalin or Concerta) only if they don’t improve. The AAP only recommends starting with medications in the most severe cases, in which both children and their families may benefit from more immediate alleviation of hyperactivity symptoms.
While the Food and Drug Administration has not approved methylphenidates for patients under age 6, the committee is basing its advice on clinical trials that suggest that the drugs are safe and effective in preschoolers. Trials on the effects of other ADHD medications, such as amphetamines, haven’t been done in younger users. For older children in school (over age 6) the AAP advises either behavioral therapy, medication or, preferably, both, to address attention problems and hyperactive behaviors.
“For kids who present during preschool with symptoms of hyperactivity and attention deficit, pediatricians have been wrestling with how to approach and manage their symptoms,” says Adesman. “What the AAP has done is provided clarification and guidance to pediatricians in terms of how to assess and treat them.”