Attention deficit/hyperactivity disorder (ADHD) is one of the most common neurobehavioral disorders of childhood. Its adverse impact is wide sweeping, affecting not only the child with ADHD, but also creating stress on parents and siblings and causing disturbances to family and marital functioning. Though it is often first diagnosed in childhood, symptoms can continue into adolescence and adulthood.ADHD can be a tremendously impairing condition, negatively affecting a person's ability to manage the multiple tasks of daily life.
There is increasing recognition about the lifelong burden associated with ADHD. Without appropriate identification and treatment, ADHD can have serious long term consequences including chronic underachievement, school/work failure, problematic and strained relationships, increased risk for substance abuse, depression, anxiety, and disruptive behavior disorders, and is associated with higher healthcare costs for individuals and their families.
The Importance of Early Detection and Intervention
There is growing understanding about the importance of early detection and early intervention. The American Academy of Pediatrics (AAP) recently updated guidelines regarding best practice for diagnosis, evaluation, and treatment of children with ADHD. The update includes recommendations that evaluation of preschool children be started at ages 4 and 5 years for ADHD and other cognitive or developmental conditions when children come for help with academic or behavioral symptoms.
Diagnosing ADHD in preschool age children can be very difficult. Poor attention and distractibility are rarely the primary concern at this age group. It is more likely that presenting problems involve noncompliant and oppositional behaviors, temper tantrums, hyperactivity, aggression, and conflict in the parent child-relationship. It is often challenging to tease out whether the underlying cause for these disruptive behaviors are due to ADHD or some other problem. Diagnosing ADHD in this young age group is possible, but requires careful consideration.
Children who are already exhibiting such disruptive behaviors at this early age are at increased risk for further problems. Early interventions can help to improve outcomes and put the child on a better trajectory. The question is what type of early intervention is most effective for this age group?
Research on Interventions for Preschool Children at Risk for ADHD
Alice Charach, MD, is Head of the Neuropsychiatry Team in the Outpatient Department of Psychiatry at the Hospital for Sick Children in Toronto and lead author of a recent paper, "Interventions for Preschool Children at High Risk for ADHD: A Comparative Effectiveness Review" published in the journal Pediatrics (online April 1, 2013/in print May 2013). To get a better understanding about the most effective intervention for this age group, Dr. Charach and her colleagues examined the medical literature for studies on interventions for children younger than 6 who had behavior disruptive enough to be referred for treatment, or a diagnosis of ADHD, oppositional defiant disorder or a conduct disorder.
Fifty-five studies from 1980 through 2011 that looked at the different treatments among preschoolers at risk for ADHD were analyzed. The literature review revealed three primary categories of intervention for disruptive behavior, including ADHD, which have been evaluated in preschool-aged children: (1) parent behavior training, (2) psychostimulant medication, specifically immediate-release methylphenidate; and (3) combinations of parent behavior training and teacher or preschool/daycare interventions.
Parent Behavior Training Interventions
In the review Dr. Charach explains that parent behavior training (PBT) interventions are designed to help parents manage their child's problem behaviors with more effective discipline strategies by using rewards and non-punitive consequences. An important aspect of PBT is to promote a positive relationship between parent and child. The training includes educational components regarding childhood behavior problems and common developmental issues, and may include coaching or consultation to support parents' efforts. Primary outcomes of PBT are improved child behavior and parenting skills.
Four PBT interventions were studied in the review - the Positive Parenting Program, Incredible Years Parenting Program, Parent-Child Interaction Therapy, and the New Forest Parenting Program. Of the 55 studies analyzed, 8 "good" studies (taking into account study design, systematic error, consistency of results, directness of evidence, and certainty of outcome) examined PBT. Strength of evidence was high for improved child behavior.
While there is an abundance of evidence that stimulants, particularly along with behavioral strategies, are both highly effective and safe in school aged children, this review noted that there was only one high-quality study which evaluated specifically the use of methylphenidate in preschool children - the multisite National Institute of Mental Health funded Preschool ADHD Treatment Study (PATS).
In addition to evaluating effectiveness of an intervention, it is important to factor in safety and adverse side effects when considering medication for this young age group. PATS offers high quality evidence about the efficacy, safety, and effectiveness of low doses of immediate-release methylphenidate, 3 times daily, for preschool age children 3 to 5 years of age, however, the study also found that children this age are more sensitive than older children to the medication side effects and therefore should be closely monitored.
It is also important to note that use of methylphenidate for children younger than 6 years of age has not been approved by the Food and Drug Administration. In addition, AAP Guidelines do not recommend medication as a first-line treatment for children at risk of ADHD in this age group.
Charach and her team concluded that with more studies consistently documenting effectiveness, PBT interventions have greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD. Combined home and school/daycare interventions showed inconsistent results.
Considering the evidence available, the best first-choice treatment for this young age group is PBT. Benefits of PBT also continue after the intervention is completed, whereas methylphenidate can be associated with higher rates of adverse side effects.
"When we look at studies with children with a cluster of disruptive behaviors, parent behavior training is a good strong intervention for behaviors like hyperactivity, impulsivity, temper tantrums and oppositional behavior," explains Dr. Charach. This is not to say that parents are to blame for their child's behavior, rather it means that some children require a different set of parenting interventions.
"Some kids are more challenging and need extra skills and extra support from their parents. And this might not come naturally. We learn to parent from our parents. If a child isn't like us, we might not know what to do," says Charach. PBT provides parents with practical, evidence-based strategies that help to improve family interactions and a child's ability to manage his or her behavior.
Additional Important Points
The review points out that it can be difficult for families to access high quality, evidence-based parent training programs. In addition, when parents do not follow through with their training sessions, benefits decrease significantly.
It is also important to note that in cases where inattention, hyperactivity, and impulsiveness continue to impair the child's functioning even after PBT, additional medical intervention may need to be considered.
Charach notes that further research is needed in the following areas: tailoring PBT interventions to specific subgroups of children and families, examining barriers to access and acceptance of PBT interventions, as well as research on the use of methylphenidate in conjunction with PBT with preschoolers.
6 Things You Need to Know If Your Child Has ADHD
Long Term Course of ADHD Diagnosed in Preschool Years Can Be Chronic and Severe
Study of Preschool Children With ADHD Finds Brain Differences Linked to Symptoms
Alice Charach, Patricia Carson, Steven Fox, Muhammad Usman Ali, Julianna Beckett. Interventions for Preschool Children at High Risk for ADHD: A Comparative Effectiveness Review, Pediatrics; originally published online April 1, 2013; DOI: 10.1542/peds.2012-0974.
US National Library of Medicine; Parent-Focused Classes May Help Tots at Risk for ADHD, MedlinePlus, Healthday, 2013.