Treatment of preschool ADHD

Attention deficit/hyperactivity disorder (ADHD) has been identified in children, and appropriate treatments studied now for over half a century. The vast majority of cases that present for treatment do so after the child starts school and concerns are raised about ability to manage academics. Yet, when asked when the symptoms first began, many parents will describe onset prior to the school years – in the preschool period. But identification of ADHD in preschoolers can be difficult because of the developmental changes that are ongoing during the period from 3 to 5 years. Many of the symptoms that one would attribute to ADHD, such as increased motor activity, inattention, and distractibility are commonplace in this age group. Furthermore, some behaviors commonly associated with ADHD, such as emotional lability and obstinacy, are nearly synonymous with being a preschooler. So, how is the diagnosis made? When is it appropriate to treat? And what would that treatment look like? The following case, where symptoms of preschool ADHD go beyond typical development, provides some guides for treatment based on the evolving literature regarding preschool ADHD.

Case Summary

Johnny is a 4-year-old boy who was the product of a complicated pregnancy and delivery. Born at 35 weeks to a 17-year-old mother with a history of tobacco use disorder and depression, he spent several weeks in the special care nursery before leaving the hospital with his mother. His early temperament was described as being “difficult” with frequent episodes of colic and trouble establishing a sleep routine. His father had a history of conduct problems and school failure, and would come in and out of the family for the first 3 years. Lately, he had moved in with Johnny and his mother, and they were trying to “make a go of it.” Johnny had been slightly behind in his developmental milestones – particularly his language – but by 4 years he was able to speak in simple sentences, was able to name his colors, and had started copying circles and squares.

His parents bring Johnny in for an appointment that they made specifically to discuss his activity level and the question of ADHD, which has been brought up by multiple family members and his preschool teacher. They describe some behaviors that you have not heard about previously because they had assumed that “this is what boys did.” At age 3 years, he impulsively ran into the road after being told “no” and was nearly struck by a car. He continually tries to put things into the toaster, and they have had to get “industrial strength” plug covers because he tries to pry them off with a kitchen knife. On multiple occasions, his mother has locked herself in her bedroom because he wouldn’t stop talking to her and she couldn’t stand it anymore. When this happens, she checks often to make sure Johnny is safe, but then calls Johnny’s father home from his job as a delivery driver because she’s at her limit. In fact, Johnny’s father has been called to the preschool to bring Johnny home so many times that his father is in danger of losing his job. While Johnny appears to be a good athlete, he is often picked last for teams because he doesn’t pay attention in the game and likes to “play his own game” of tackling the other children. The stress of raising Johnny is weighing on the parents’ relationship, and Johnny’s father is considering moving out again. The parents ask for an assessment and treatment, preferably with medication.

Case Discussion

Johnny very likely has ADHD. However, to take appropriate caution in the diagnosis, one would consider that he needs to have six of nine criteria of inattention (being careless, difficulty sustaining attention, not listening, not following through, avoiding hard mental tasks, not organizing, losing important items, being easily distractible, and being forgetful) and/or six of nine criteria of hyperactivity/impulsivity (squirming/fidgeting, can’t stay seated, running or climbing excessively, can’t play quietly, “driven by a motor,” talking excessively, blurting out answers, not waiting his turn, and interrupting/intruding on others). As with school-aged ADHD, there need to be symptoms that are frequent (“often”) and that interfere with home, academic, or occupational function. One must take into account the base rate for these symptoms in preschoolers. For example, Willoughby and colleagues (J. Abnorm. Child Psychol. 2012;40:1301-12) demonstrated that at age 4 years, 26.3% of children fidget or squirm, 39.5% act as if “driven by a motor,” 46.3% talk excessively, 28.8% are easily distracted, and 25.4% have difficult waiting their turn. In fact, on average, a 4-year-old will have 1.3 inattentive items and 2.4 hyperactive-impulsive items. Still, Johnny seems to have more than his fair share. This can be validated by a) doing a careful evaluation over time using multiple informants, b) taking a family history, c) looking at developmental signs and ruling out other developmental disorders, d) making physical observations in the office (although these can be deceiving) and e) having the parents and others complete parent and caregiver checklists.

When asking parents and caregivers to complete checklists, it is crucial to make sure that these checklists look for symptoms other than just ADHD, because there are often co-occurring symptoms and disorders. These include oppositional defiant disorder, anxiety, obsessive compulsive disorder, depressive disorders, autism spectrum disorders, trauma, and learning/communication disorders. In fact, the Preschool ADHD Treatment Study (PATS) demonstrated that 71.5% of children with preschool ADHD had at least one other diagnosis and 29.7% had two or more (J. Child Adolesc. Psychopharmacol. 2007;17:563-80). Use of a broad-based instrument that captures all of these domains, in addition to attention, is warranted. In our clinic, we also assess the parents for psychopathology using the same instruments. The reason for this is, first, that family history increases the likelihood of an ADHD diagnosis and, perhaps more importantly, presence of family psychopathology makes treatment more difficult. This is because the treatment you will prescribe is going to actively involve the parents.

The treatment of choice for preschool ADHD, based on practice parameters and expert opinion, is to start with family-based behavioral treatments. There are now several empirically-based treatments that have shown efficacy for the symptoms of inattention and hyperactivity-impulsivity in preschoolers. These include Triple P (“Practitioner’s Manual for Enhanced Triple P” [Brisbane: Families International Publishing, 1998]), The Incredible Years (Webster-Stratton & Hancock, 1998), and the Revised New Forest Parent Program (Daley & Thompson, 2007), among others. If these are not available in your community, other options would be “Helping the noncompliant child: A clinician’s guide to effective parent training,” 2nd ed. (The Guilford Press: New York, 2003) or any other empirically-based parent training program. This is why it is critical to engage the parents in treatment and to refer them for treatment for their own psychopathology, if present. Furthermore, engaging the family in a program of wellness (freedom from substances, enhanced nutrition, avoidance of artificial food coloring, increased exercise), has less of a research base, but the available evidence is that it is helpful.

If medications become necessary because of safety concerns, there are few options that have a Food and Drug Administration indication. Those that do have an indication for disruptive behavior below the age of 5 years (haloperidol, dextroamphetamine, chlorpromazine, and risperidone) should not be considered as first line. The PATS study demonstrated the safety and efficacy of methylphenidate, but with optimal doses lower than those seen in school-aged children (0.7 mg/kg per day) and with increased numbers of adverse effects (11% discontinuing) (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1284-93; J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294-303).

Because of the increased amount of side effects, medication treatment cannot be considered as the first treatment. Treatment with nonstimulants is poorly studied. Any treatment with methylphenidate would be considered off-label prescribing, which must be done with great caution and, preferably, in consultation with a child and adolescent psychiatrist.

The diagnosis and management of ADHD in the very young is tricky, but possible. Doing a comprehensive evaluation with information from multiple informants, assessing and treating the parents for psychopathology, engaging the family in wellness, and starting with behavioral management is the way to go. If you feel that medication treatment is necessary for safety of the little ones, it’s best to consult, because none of the medications with FDA indication are likely to be the answer.

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff receives no funding from pharmaceutical companies or industry. He has grant funding from the National Institute of General Medical Sciences and the Klingenstein Third Generation Foundation, and is employed, in part, by the nonprofit Research Center for Children, Youth, and Families that develops the Child Behavior Checklist and associated instruments. E-mail him at [email protected].

Attention deficit/hyperactivity disorder (ADHD) has been identified in children, and appropriate treatments studied now for over half a century. The vast majority of cases that present for treatment do so after the child starts school and concerns are raised about ability to manage academics. Yet, when asked when the symptoms first began, many parents will describe onset prior to the school years – in the preschool period. But identification of ADHD in preschoolers can be difficult because of the developmental changes that are ongoing during the period from 3 to 5 years. Many of the symptoms that one would attribute to ADHD, such as increased motor activity, inattention, and distractibility are commonplace in this age group. Furthermore, some behaviors commonly associated with ADHD, such as emotional lability and obstinacy, are nearly synonymous with being a preschooler. So, how is the diagnosis made? When is it appropriate to treat? And what would that treatment look like? The following case, where symptoms of preschool ADHD go beyond typical development, provides some guides for treatment based on the evolving literature regarding preschool ADHD.

Case Summary

Johnny is a 4-year-old boy who was the product of a complicated pregnancy and delivery. Born at 35 weeks to a 17-year-old mother with a history of tobacco use disorder and depression, he spent several weeks in the special care nursery before leaving the hospital with his mother. His early temperament was described as being “difficult” with frequent episodes of colic and trouble establishing a sleep routine. His father had a history of conduct problems and school failure, and would come in and out of the family for the first 3 years. Lately, he had moved in with Johnny and his mother, and they were trying to “make a go of it.” Johnny had been slightly behind in his developmental milestones – particularly his language – but by 4 years he was able to speak in simple sentences, was able to name his colors, and had started copying circles and squares.

His parents bring Johnny in for an appointment that they made specifically to discuss his activity level and the question of ADHD, which has been brought up by multiple family members and his preschool teacher. They describe some behaviors that you have not heard about previously because they had assumed that “this is what boys did.” At age 3 years, he impulsively ran into the road after being told “no” and was nearly struck by a car. He continually tries to put things into the toaster, and they have had to get “industrial strength” plug covers because he tries to pry them off with a kitchen knife. On multiple occasions, his mother has locked herself in her bedroom because he wouldn’t stop talking to her and she couldn’t stand it anymore. When this happens, she checks often to make sure Johnny is safe, but then calls Johnny’s father home from his job as a delivery driver because she’s at her limit. In fact, Johnny’s father has been called to the preschool to bring Johnny home so many times that his father is in danger of losing his job. While Johnny appears to be a good athlete, he is often picked last for teams because he doesn’t pay attention in the game and likes to “play his own game” of tackling the other children. The stress of raising Johnny is weighing on the parents’ relationship, and Johnny’s father is considering moving out again. The parents ask for an assessment and treatment, preferably with medication.

Case Discussion

Johnny very likely has ADHD. However, to take appropriate caution in the diagnosis, one would consider that he needs to have six of nine criteria of inattention (being careless, difficulty sustaining attention, not listening, not following through, avoiding hard mental tasks, not organizing, losing important items, being easily distractible, and being forgetful) and/or six of nine criteria of hyperactivity/impulsivity (squirming/fidgeting, can’t stay seated, running or climbing excessively, can’t play quietly, “driven by a motor,” talking excessively, blurting out answers, not waiting his turn, and interrupting/intruding on others). As with school-aged ADHD, there need to be symptoms that are frequent (“often”) and that interfere with home, academic, or occupational function. One must take into account the base rate for these symptoms in preschoolers. For example, Willoughby and colleagues (J. Abnorm. Child Psychol. 2012;40:1301-12) demonstrated that at age 4 years, 26.3% of children fidget or squirm, 39.5% act as if “driven by a motor,” 46.3% talk excessively, 28.8% are easily distracted, and 25.4% have difficult waiting their turn. In fact, on average, a 4-year-old will have 1.3 inattentive items and 2.4 hyperactive-impulsive items. Still, Johnny seems to have more than his fair share. This can be validated by a) doing a careful evaluation over time using multiple informants, b) taking a family history, c) looking at developmental signs and ruling out other developmental disorders, d) making physical observations in the office (although these can be deceiving) and e) having the parents and others complete parent and caregiver checklists.

When asking parents and caregivers to complete checklists, it is crucial to make sure that these checklists look for symptoms other than just ADHD, because there are often co-occurring symptoms and disorders. These include oppositional defiant disorder, anxiety, obsessive compulsive disorder, depressive disorders, autism spectrum disorders, trauma, and learning/communication disorders. In fact, the Preschool ADHD Treatment Study (PATS) demonstrated that 71.5% of children with preschool ADHD had at least one other diagnosis and 29.7% had two or more (J. Child Adolesc. Psychopharmacol. 2007;17:563-80). Use of a broad-based instrument that captures all of these domains, in addition to attention, is warranted. In our clinic, we also assess the parents for psychopathology using the same instruments. The reason for this is, first, that family history increases the likelihood of an ADHD diagnosis and, perhaps more importantly, presence of family psychopathology makes treatment more difficult. This is because the treatment you will prescribe is going to actively involve the parents.

The treatment of choice for preschool ADHD, based on practice parameters and expert opinion, is to start with family-based behavioral treatments. There are now several empirically-based treatments that have shown efficacy for the symptoms of inattention and hyperactivity-impulsivity in preschoolers. These include Triple P (“Practitioner’s Manual for Enhanced Triple P” [Brisbane: Families International Publishing, 1998]), The Incredible Years (Webster-Stratton & Hancock, 1998), and the Revised New Forest Parent Program (Daley & Thompson, 2007), among others. If these are not available in your community, other options would be “Helping the noncompliant child: A clinician’s guide to effective parent training,” 2nd ed. (The Guilford Press: New York, 2003) or any other empirically-based parent training program. This is why it is critical to engage the parents in treatment and to refer them for treatment for their own psychopathology, if present. Furthermore, engaging the family in a program of wellness (freedom from substances, enhanced nutrition, avoidance of artificial food coloring, increased exercise), has less of a research base, but the available evidence is that it is helpful.

If medications become necessary because of safety concerns, there are few options that have a Food and Drug Administration indication. Those that do have an indication for disruptive behavior below the age of 5 years (haloperidol, dextroamphetamine, chlorpromazine, and risperidone) should not be considered as first line. The PATS study demonstrated the safety and efficacy of methylphenidate, but with optimal doses lower than those seen in school-aged children (0.7 mg/kg per day) and with increased numbers of adverse effects (11% discontinuing) (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1284-93; J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294-303).

Because of the increased amount of side effects, medication treatment cannot be considered as the first treatment. Treatment with nonstimulants is poorly studied. Any treatment with methylphenidate would be considered off-label prescribing, which must be done with great caution and, preferably, in consultation with a child and adolescent psychiatrist.

The diagnosis and management of ADHD in the very young is tricky, but possible. Doing a comprehensive evaluation with information from multiple informants, assessing and treating the parents for psychopathology, engaging the family in wellness, and starting with behavioral management is the way to go. If you feel that medication treatment is necessary for safety of the little ones, it’s best to consult, because none of the medications with FDA indication are likely to be the answer.

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff receives no funding from pharmaceutical companies or industry. He has grant funding from the National Institute of General Medical Sciences and the Klingenstein Third Generation Foundation, and is employed, in part, by the nonprofit Research Center for Children, Youth, and Families that develops the Child Behavior Checklist and associated instruments. E-mail him at [email protected].

Attention deficit/hyperactivity disorder (ADHD) has been identified in children, and appropriate treatments studied now for over half a century. The vast majority of cases that present for treatment do so after the child starts school and concerns are raised about ability to manage academics. Yet, when asked when the symptoms first began, many parents will describe onset prior to the school years – in the preschool period. But identification of ADHD in preschoolers can be difficult because of the developmental changes that are ongoing during the period from 3 to 5 years. Many of the symptoms that one would attribute to ADHD, such as increased motor activity, inattention, and distractibility are commonplace in this age group. Furthermore, some behaviors commonly associated with ADHD, such as emotional lability and obstinacy, are nearly synonymous with being a preschooler. So, how is the diagnosis made? When is it appropriate to treat? And what would that treatment look like? The following case, where symptoms of preschool ADHD go beyond typical development, provides some guides for treatment based on the evolving literature regarding preschool ADHD.

Case Summary

Johnny is a 4-year-old boy who was the product of a complicated pregnancy and delivery. Born at 35 weeks to a 17-year-old mother with a history of tobacco use disorder and depression, he spent several weeks in the special care nursery before leaving the hospital with his mother. His early temperament was described as being “difficult” with frequent episodes of colic and trouble establishing a sleep routine. His father had a history of conduct problems and school failure, and would come in and out of the family for the first 3 years. Lately, he had moved in with Johnny and his mother, and they were trying to “make a go of it.” Johnny had been slightly behind in his developmental milestones – particularly his language – but by 4 years he was able to speak in simple sentences, was able to name his colors, and had started copying circles and squares.

His parents bring Johnny in for an appointment that they made specifically to discuss his activity level and the question of ADHD, which has been brought up by multiple family members and his preschool teacher. They describe some behaviors that you have not heard about previously because they had assumed that “this is what boys did.” At age 3 years, he impulsively ran into the road after being told “no” and was nearly struck by a car. He continually tries to put things into the toaster, and they have had to get “industrial strength” plug covers because he tries to pry them off with a kitchen knife. On multiple occasions, his mother has locked herself in her bedroom because he wouldn’t stop talking to her and she couldn’t stand it anymore. When this happens, she checks often to make sure Johnny is safe, but then calls Johnny’s father home from his job as a delivery driver because she’s at her limit. In fact, Johnny’s father has been called to the preschool to bring Johnny home so many times that his father is in danger of losing his job. While Johnny appears to be a good athlete, he is often picked last for teams because he doesn’t pay attention in the game and likes to “play his own game” of tackling the other children. The stress of raising Johnny is weighing on the parents’ relationship, and Johnny’s father is considering moving out again. The parents ask for an assessment and treatment, preferably with medication.

Case Discussion

Johnny very likely has ADHD. However, to take appropriate caution in the diagnosis, one would consider that he needs to have six of nine criteria of inattention (being careless, difficulty sustaining attention, not listening, not following through, avoiding hard mental tasks, not organizing, losing important items, being easily distractible, and being forgetful) and/or six of nine criteria of hyperactivity/impulsivity (squirming/fidgeting, can’t stay seated, running or climbing excessively, can’t play quietly, “driven by a motor,” talking excessively, blurting out answers, not waiting his turn, and interrupting/intruding on others). As with school-aged ADHD, there need to be symptoms that are frequent (“often”) and that interfere with home, academic, or occupational function. One must take into account the base rate for these symptoms in preschoolers. For example, Willoughby and colleagues (J. Abnorm. Child Psychol. 2012;40:1301-12) demonstrated that at age 4 years, 26.3% of children fidget or squirm, 39.5% act as if “driven by a motor,” 46.3% talk excessively, 28.8% are easily distracted, and 25.4% have difficult waiting their turn. In fact, on average, a 4-year-old will have 1.3 inattentive items and 2.4 hyperactive-impulsive items. Still, Johnny seems to have more than his fair share. This can be validated by a) doing a careful evaluation over time using multiple informants, b) taking a family history, c) looking at developmental signs and ruling out other developmental disorders, d) making physical observations in the office (although these can be deceiving) and e) having the parents and others complete parent and caregiver checklists.

When asking parents and caregivers to complete checklists, it is crucial to make sure that these checklists look for symptoms other than just ADHD, because there are often co-occurring symptoms and disorders. These include oppositional defiant disorder, anxiety, obsessive compulsive disorder, depressive disorders, autism spectrum disorders, trauma, and learning/communication disorders. In fact, the Preschool ADHD Treatment Study (PATS) demonstrated that 71.5% of children with preschool ADHD had at least one other diagnosis and 29.7% had two or more (J. Child Adolesc. Psychopharmacol. 2007;17:563-80). Use of a broad-based instrument that captures all of these domains, in addition to attention, is warranted. In our clinic, we also assess the parents for psychopathology using the same instruments. The reason for this is, first, that family history increases the likelihood of an ADHD diagnosis and, perhaps more importantly, presence of family psychopathology makes treatment more difficult. This is because the treatment you will prescribe is going to actively involve the parents.

The treatment of choice for preschool ADHD, based on practice parameters and expert opinion, is to start with family-based behavioral treatments. There are now several empirically-based treatments that have shown efficacy for the symptoms of inattention and hyperactivity-impulsivity in preschoolers. These include Triple P (“Practitioner’s Manual for Enhanced Triple P” [Brisbane: Families International Publishing, 1998]), The Incredible Years (Webster-Stratton & Hancock, 1998), and the Revised New Forest Parent Program (Daley & Thompson, 2007), among others. If these are not available in your community, other options would be “Helping the noncompliant child: A clinician’s guide to effective parent training,” 2nd ed. (The Guilford Press: New York, 2003) or any other empirically-based parent training program. This is why it is critical to engage the parents in treatment and to refer them for treatment for their own psychopathology, if present. Furthermore, engaging the family in a program of wellness (freedom from substances, enhanced nutrition, avoidance of artificial food coloring, increased exercise), has less of a research base, but the available evidence is that it is helpful.

If medications become necessary because of safety concerns, there are few options that have a Food and Drug Administration indication. Those that do have an indication for disruptive behavior below the age of 5 years (haloperidol, dextroamphetamine, chlorpromazine, and risperidone) should not be considered as first line. The PATS study demonstrated the safety and efficacy of methylphenidate, but with optimal doses lower than those seen in school-aged children (0.7 mg/kg per day) and with increased numbers of adverse effects (11% discontinuing) (J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1284-93; J. Am. Acad. Child Adolesc. Psychiatry 2006;45:1294-303).

Because of the increased amount of side effects, medication treatment cannot be considered as the first treatment. Treatment with nonstimulants is poorly studied. Any treatment with methylphenidate would be considered off-label prescribing, which must be done with great caution and, preferably, in consultation with a child and adolescent psychiatrist.

The diagnosis and management of ADHD in the very young is tricky, but possible. Doing a comprehensive evaluation with information from multiple informants, assessing and treating the parents for psychopathology, engaging the family in wellness, and starting with behavioral management is the way to go. If you feel that medication treatment is necessary for safety of the little ones, it’s best to consult, because none of the medications with FDA indication are likely to be the answer.

Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff receives no funding from pharmaceutical companies or industry. He has grant funding from the National Institute of General Medical Sciences and the Klingenstein Third Generation Foundation, and is employed, in part, by the nonprofit Research Center for Children, Youth, and Families that develops the Child Behavior Checklist and associated instruments. E-mail him at [email protected].