October 16th, 2011
12:01 AM ET
The American Academy of Pediatrics has broadened its guidelines for attention deficit hyperactivity disorder, expanding the age range for diagnosis and treatment to ages 4 through 18.
While the previous guidelines, from 2000 and 2001, targeted children ages 6 to 12, the new report covers children from preschool to the end of high school. This is based on recent evidence that supports including preschool children and adolescents in ADHD diagnosis and treatment management.
"The primary care clinician should initiate an evaluation for ADHD for any child 4 though 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity," the report said.
Children as young as 4 are already receiving diagnoses of ADHD, but with this report the American Academy of Pediatrics codifies how to approach preschoolers with these symptoms, said Dr. Jonathan Posner, assistant professor of clinical psychiatry at Columbia University Medical School.
Diagnoses of ADHD are on the rise, with 9% of children having it in 2007-2009, according to the Centers for Disease Control and Prevention. That's an increase from previous estimate of 7%.
For ages 4 to 5, the report recommends behavioral interventions first, but if there's no improvement and the child has moderate to severe symptoms, the stimulant drug methylphenidate (marketed as Ritalin, Concerta and others) may be used.
Behavioral interventions include parent-training programs, which may involve learning how to deliver positive reinforcement, helping a child stay organized and generally managing a child. If children qualify for Early Childhood Special Education services through local school systems, their program evaluators and teachers may be able to keep track of a child's ADHD symptoms.
Research in the last few years has shown that methylphenidate is safe and effective in the preschool age group, Posner said. However, these kids tend to be more prone to short-term side effects, such as mood swings, lack of appetite and insomnia, which tend to be manageable. And sometimes methylphenidate leads to slowing of the growth in children, as well as eyesight changes. Patients with a history of seizures may be more prone to seizures.
Long-term side effects haven't entirely been ruled out, but parents should also consider that the condition itself can lead to significant problems, Posner said.
"When you consider the potential benefit of ameliorating the symptoms, it can outweigh the potential risk of long-term side effects," Posner said.
Although Posner views the guidelines for preschoolers positively, Dr. Claudia Gold, a pediatrician and child mental health, expert is concerned that they will lead to more overdiagnosis and overmedication in the preschool group. In fact, a 2010 study found that there are already nearly 1 million children with a misdiagnosis of ADHD. In her opinion, below age 6 is too soon for ADHD medications.
ADHD is a constellation of symptoms representing problems of emotion, regulation and attention. Treating children as young as possible is important, but that doesn't mean their problems are necessarily ADHD, or that ADHD medication is the best answer, Gold said. The ADHD label excludes many other possibilities that could be leading to a young child to be hyperactive and inattentive, such as sleep deprivation and family conflict.
"Once there’s the question of ADHD rather than the question 'What’s going on for this child?' already you’ve narrowed your thinking," she said.
Because the brain is more amenable to change at early ages, interventions that are more relational or involve working with a parent and child together can have a bigger impact in the preschool years than at ages 7 to 9, Gold said.
"If you just look at what are the symptoms and what is the label, you miss a lot. But that is the standard of care, that’s how it works, which is how kids get all those labels," she said.
The guidelines also address how to approach ADHD in teenagers, a change that Gold praised because it is sometimes the case that young people don't present with clear symptoms until adolescents. For middle- and high schoolers, who probably have multiple teachers and spend less time with their parents, keeping track of symptoms may be more challenging than for younger children.
Clinicians should try to get reports on symptoms from at least two teachers and other people from the school or community, the new guidelines say. Doctors should also try to establish whether these behavioral and attention problems were present earlier in the child's life, and perhaps missed.
ADHD in adolescents increases the likelihood of substance abuse, especially when untreated, as well as the risky sexual behaviors and mood and anxiety disorders.
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