SUNDAY, Oct. 16 — For the first time in 10 years, the American Academy of Pediatrics (AAP) has revised its recommendations for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) in children. Among the biggest changes is the inclusion of preschoolers (4- to 5-year-olds) and adolescents (13- to 18-year-olds); previously, the guidelines focused only on kids between the ages of 6 and 12.
According to the U.S. Centers for Disease Control and Prevention, ADHD affects some 5.4 million children in the United States — more than half of whom are 11 or younger. Of those, as many as two-thirds exhibited symptoms at or before age 4, according to a study in the Journal of Developmental & Behavioral Pediatrics.
Diagnosing ADHD in children that young is complex and somewhat controversial. After all, most 4- and 5-year-olds are fidgety or have energy to burn — but how many of them actually need to be treated for it? The new AAP recommendations clear up some of that confusion for pediatricians and other health professionals, but parents of preschoolers should be aware of the signs and recommendations, too. Here’s what you need to know:
Is Your Preschooler’s Behavior Normal?
The AAP’s guidelines state that a diagnosis of ADHD should be based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which lists 18 symptoms for ADHD in children and adults: nine related to inattention, and nine related to hyperactivity and impulsivity. Only the latter — which include frequent fidgeting, excessive running around or climbing, excessive talking, difficulty playing quietly, and tendency to interrupt or blurt out answers before questions have been asked — apply to preschool-age kids.
“When we’re talking about ADHD in preschool children, we’re not talking about the inattentive form,” explains Andrew Adesman, MD, chief of developmental and behavioral pediatrics at Schneider Children's Hospital in New Hyde Park, N.Y., and a member of the advisory board for CHADD (Children and Adults with Attention-Deficit/Hyperactivity Disorder). “We’re talking about children who are hyperactive and impulsive who may or may not have significant problems with distractibility.” Among the possible red flags, he says, are restlessness, difficulty sitting still, and trouble waiting for their turn.
But if that sounds like your preschooler, don’t panic. “You’ll see some of these behaviors in all youngsters from time to time,” says Everyday Health medical director Mallika Marshall, MD, a physician at the Massachusetts General Hospital Chelsea Urgent Care Clinic and a mother of three young children herself.
So how do you know if your kid is just being a kid — or if he needs to be evaluated for ADHD?
Diagnosing ADHD in Preschoolers
“The key, and this is true for all ages, is that the behavior has to impair function and occur in two or more settings,” says Dr. Adesman. “It’s not enough to just look for those nine symptoms — you have to also consider to what extent the behavior interferes with their abilities and exists outside the home.”
That second point is probably the most important when it comes to diagnosing preschoolers, Adesman adds. “The children really have to have difficulties not just in the home, but in the eyes of someone else such as a daycare worker, a preschool teacher, or even a grandparent,” he says. The problem with this, as the AAP notes in its report, is that not all preschoolers are actually in preschool.
“With older children, there are usually other grown-ups — like teachers, coaches, or counselors — who can provide information that can help in the diagnosis of ADHD,” says Dr. Marshall. “But many preschoolers aren’t in school yet, and even if they are, their teachers may not be equipped to make a thorough behavioral assessment.”
In those cases, Adesman says, it may be necessary for parents to get a referral to a preschool or other special-education program where staff can evaluate and work with the child as necessary. “Pediatricians really should not be rushing to make an ADHD diagnosis when a parent is the only one providing information about the child’s behavior,” he warns.
If ADHD is suspected, your child’s doctor will first need to do a physical and neurological exam to rule out other conditions, such as a learning disability, anxiety, or seizures. Then, using information gathered from parents and other adults about the child’s behavior, as well as from interviews with the child himself, the doctor will evaluate the severity and frequency of the symptoms against the criteria specified in the DSM.
Treating ADHD in Preschoolers
If it turns out that your child does have ADHD, getting proper and prompt treatment is important to manage symptoms. The AAP’s new guidelines spell out recommendations by age: For kids 6 to 18, the suggested plan is a combination of medication, such as methylphenidate (Ritalin), and behavioral therapy, with an increasing emphasis on the former as the child gets older. For preschool-age kids, however, the organization favors behavioral therapy alone as the first line of treatment.
According to the Preschool ADHD Treatment Study (PATS), a long-term, comprehensive review of more than 300 children between the ages of 3 and 5, behavioral therapy is a successful and safe option for many families. One-third of kids studied did not need additional drug therapy to manage their condition. Those who did require medication experienced significant improvements with methylphenidate — but were also prone to severe side effects such as appetite reduction, anxiety, and insomnia. The drugs may stunt preschoolers’ growth, too, though more research is needed to confirm this.
For these reasons, parents and doctors should attempt to manage symptoms without medications first, and then weigh the risks and benefits of drugs only if the child does not respond to behavioral therapy.
Such therapy generally involves parent-administered behavior modification techniques, such as offering consistent praise, ignoring negative behavior, and using time-outs. Dr. Marshall advises also giving your child some structure by setting routines for bedtime, bath time, mealtime, and before school or daycare.
If therapy is ineffective or unavailable, the AAP says medication may be prescribed, though in lower doses than are given to older kids. “Pediatricians should not be rushing in with medication casually,” says Adesman. “But at the same time, it should be considered, especially when there are concerns about the behavior impacting the safety of the child or a sibling, or when symptoms are interfering with the child’s developmental abilities.”
Last Updated: 10/16/2011