ADHD in Preschoolers

Many pediatricians are incorrectly treating attention deficit hyperactivity disorder (ADHD) in very young children, according to a group of specialists from the Cohen Children’s Medical Center of New York.

Pediatric researchers from the Cohen center recently presented new ADHD findings focused on preschool-aged children to their colleagues at the Pediatric Academic Societies in Washington, D.C.

The American Academy of Pediatrics (AAP) recommends that behavioral therapy be used as the first-line treatment for preschoolers, and that methylphenidate, better known as Ritalin or Concerta, be prescribed only after behavior management therapies have been tried without success.

"Although the AAP's new ADHD guidelines were developed for primary care pediatricians, it is clear that many medical sub-specialists who care for young children with ADHD fail to follow [them]," said lead study author Jaeah Chung, M.D., in a press release. "At a time when there are public and professional concerns about over-medication of young children with ADHD, it seems that many medical specialists are recommending medication as part of their initial treatment plan for these children.”

The study results indicate that some pediatricians prescribe medication too soon, while others don’t prescribe it at all, even as a second-line treatment. In addition, some doctors prescribe drugs that are not AAP recommended and for which there isn’t enough supporting research in young children.

Andrew Adesman, M.D., chief of developmental and behavioral pediatrics at Cohen Children's Medical Center, was the study's senior investigator. “I think it is important that physicians caring for preschool children with ADHD be reminded that parent- and/or teacher-administered behavior therapy should be the first line of therapy,” he said in an interview with Healthline.

Changing Guidelines for Medicating Young Children

According to Adesman, there's research to show the safety and effectiveness of methylphenidate for preschoolers, but not enough research to support the use of amphetamines, such as Adderall, in kids so young.

For this reason, the AAP chose to limit its recommendation to the psycho-stimulant methylphenidate. However, conflicting recommendations and the relatively recent acceptance of ADHD diagnoses in preschoolers makes it difficult for doctors to know just which drug to prescribe.

“The irony is that some of the amphetamine preparations have FDA approval for use in children ages three to five but [these] are not recommended by the AAP, whereas methylphenidate is not approved by the FDA for use below age six, and yet it is the medication specifically recommended by the AAP,” Adesman said.  

Key Study Findings

Adesman and Chung's study incorporated survey responses from 560 board-certified pediatric sub-specialists, a group that includes developmental-behavioral pediatricians, child psychiatrists, and child neurologists. The study was limited to the treatment of preschoolers with ADHD.

On both counts (using behavioral therapy as a first-line treatment, and methylphenidate as a first-line medication), only 12 percent of child psychiatrists, eight percent of developmental-behavioral pediatricians, and nine percent of child neurologists comply with AAP guidelines.

Of the doctors surveyed:

  • 21 percent reported using medication as a first-line treatment "often" or "very often." 
  • 38 percent said they prescribe a medication other than methylphenidate initially.
    • 19 percent prescribe amphetamines first.
    • 19 percent prescribe non-stimulants first.

Nearly 20 percent of the pediatricians said they expect the number of ADHD cases they will treat with drugs to increase in the future.

What Parents Should Know

The number of children being diagnosed with ADHD is on the rise. Data from the Centers for Disease Control and Prevention released this year show a 16 percent increase in ADHD diagnoses in schoolchildren since 2007.

According to Adesman, because the new AAP guidelines allow for the diagnosis of ADHD in children as young as three, it's likely that more children will be diagnosed with ADHD even before entering kindergarten.

Early childhood professionals at preschools are often trained in behavior management strategies. They can provide objective observations about a child’s behavior in a setting outside the home, which can help the child's doctor diagnose and treat ADHD.

“If a parent is concerned that their preschool child is overactive, enrolling the child in a mainstream or special education preschool program may help both the parent and the child,”  Adesman said.

It's also important for parents to stay informed and ask questions about whither their child’s pediatrician follows clinical recommendations in treating ADHD.

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