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Pediatricians Lower ADHD Age From Six to Four

Diagnosis and treatment, including medications, extended to preschoolers  

Caroline Miller

Editorial Director
Child Mind Institute

Pediatricians are making news, and raising eyebrows, by lowering the official age that they can diagnose a child with ADHD from six to four.

The new guidelines, released at the American Academy of Pediatrics annual meeting in Boston yesterday, are generating headlines because they include the use of stimulant medications in preschool-age children.

The new guidelines recommend behavioral therapy as the first response to an ADHD diagnosis, but add that prescribing methylphenidate, known by the brand name Ritalin, is appropriate for treating kids with moderate to severe symptoms when behavioral interventions aren't effective.

"Ritalin added as option for 4-year-olds," blares the headline on one story, cutting to the most controversial aspect. One psychiatrist predictes "a further feeding frenzy of aggressive marketing by drug companies."

But the reality is that the guidelines are changing because many pediatricians have already been seeing preschool children with severe ADHD—children whose hyperactivity and impulsivity are seriously impairing—and they've been prescribing stimulant medications when necessary. These kids are on a collision course with their families and peers.

"We're trying to prevent kids from getting messages that make them think that they're bad kids, or they're not as smart as other kids, or they in some ways have serious problems," Dr. Mark Wolraich, lead author and a professor of pediatrics at the University of Oklahoma Health Sciences Center, tells the Vancouver Sun. "We're really trying to prevent them having a lot of failure early on."

He notes that the recommendation isn't for borderline kids, but those who are showing serious dysfunction—kids who are out of control at home, who've been kicked out of preschool and blackballed by other families because of disruptive behavior and impulsivity.

At the Child Mind Institute that doesn't surprise us, because we've seen many of these children, children whose ADHD is interfering with their development, and wreaking havoc in their families.

"By the time they're 4-years-old they're already getting into trouble at circle time, at birthday parties, at family gatherings," says Steven Kurtz, PhD, APBB, senior director of the Child Mind Institute's ADHD and Disruptive Behavior Disorders Center.  "Every day that a four-year-old fails at being a child chips away at his self esteem, and that every day we can help him contributes to rebuilding it."

Behavioral treatment, especially Parent-Child Interaction Therapy, can be very helpful in reining in disruptive behavior. But the core symptoms of ADHD respond only to medication. Dr. Kurtz cites a multi-year study of 300 children at the National Institute of Mental Health, completed in 2006, that demonstrated the safety and effectiveness of low doses of methylphenidate (Ritalin) for children from age three to five. The preschoolers were found to respond to surprisingly low doses, though they were also more sensitive to side effects—11 percent of the kids in the study, all of whom had severe ADHD symptoms that were not ameliorated by behavioral therapy, had to drop out because of weight loss or insomnia. Close monitoring, the NIMH noted, is especially critical for young children.  

The Diagnostic and Statistical Manual, which psychiatrists use for diagnosis, has no lower age limit on ADHD. It stipulates that the symptoms of hyperactivity, inattention, and impulsivity must be outside the typical range, must have been in evidence for at least six months, and must manifest in more than one environment. It also notes that in preschool children the hyperactivity and impulsivity are usually what get attention, while inattention isn't noticed until children start school.

That said, the FDA  hasn't approved the use of stimulants for children under six years of age. That doesn't mean, notes Alan Ravitz, MD, that there isn't substantial evidence of their effectiveness and safety. "The FDA guidelines haven't approved giving medicine to kids under six because it is difficult to do research on kids, because you need to do double blind studies, and have informed consent," says Dr. Ravitz. " Withholding treatment from kids who are seriously struggling is also problematic."

Published: October 17, 2011

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