The diagnosis of Attention Deficit Hyperactivity Disorder (ADHD) is becoming increasingly prevalent, in part because of better assessments, but also in part because of misdiagnosis and jumping too early to diagnose. The effect is that the diagnosis of ADHD is being given at younger and younger ages. This leads to the question of the best practice for the treatment for ADHD in children under the age of 5. The first challenge is that often young children do not fully meet the criteria for ADHD. It is particularly challenging to determine if a young child qualifies for the inattention subtype of ADHD because a short attention span is developmentally appropriate for young children, and frequently parents have unrealistic expectations for how focused their young children should be. In making a provisional diagnosis of ADHD in a younger child, it is important to determine whether ADHD symptoms are persistent throughout the day rather than time or situation specific—it is the rare toddler or preschool child who does not present with inattention or hyperactivity when it is way past their bedtime or when they are in a stressful environmental situation.
While medication for ADHD is often the first line treatment for older children and adolescents with ADHD, it is not the recommended first line treatment for young children with ADHD symptoms. Both the CDC and AAP urges healthcare providers to refer parents of young children with ADHD for behavioral therapy training before prescribing medication to treat the symptoms. Research shows that behavioral therapy can be as effective as medication, being 70-80% effective for treating the core symptoms of ADHD in young children.
Where the problem lies is that less than 50% of young children are referred to parent behavioral therapy training. While behavior therapy can take more time, effort, and resources than medication, the effects last much longer past when the treatment ends, unlike medication. Another concern is that stimulant medication in young children can have problematic side effects, including irritability, increased agitation, appetite suppression, growth delay, and sleep disturbance.
In clinical practice, psychotropic medication for ADHD symptoms has been shown to not work as reliably and robustly in younger children as they do in older children. This could occur when ADHD is not the correct diagnosis, as children with trauma or anxiety or sensory challenges can also present with hyperactivity and impulsivity, but would respond poorly to a stimulant medication. The other major reason is that the commonly seen side effects with stimulant medications (sleep and appetite disturbance, moodiness) can have more impact on young children, who are physically growing at a faster pace and are still developing core social/emotional and behavioral processes, as compared to older children, who are typically more mature in all of these areas.
Of course, there are situations where medication interventions may be warranted for preschool children, such as when a young child is so persistently hyperactive, agitated and/or aggressive throughout the day such that placements in preschool or recreational programs become threatened, but even in these situations, the use of medication should be best seen as a provisional supplemental intervention that will enable behavioral and parent training interventions to be applied. Careful consideration as to whether a stimulant medication or an alpha-agonist preparation should be administered is warranted, with the goal of reducing the extreme disruptive behaviors that impair engagement and functioning at home and in community settings. Reconsideration of the need for ongoing treatment in these cases is appropriate as the impact of behavioral therapies and the normative developmental process may improve their clinical profile.
In summary, when considering the diagnosis of ADHD in a young child, it is important to conduct a careful assessment, looking for other mood/anxiety, developmental, and medical symptoms, prior to confirming the diagnosis and initiating pharmacologic treatment. If a young child does meet criteria for ADHD, the first-line recommended treatment is parent training for behavioral therapy, before considering medication. Because we know it is hard to help families find resources, parents can be referred to the SmartCare Parent Line to help find an appropriate program to meet their needs.
References:
1) Preschoolers and ADHD: Recommended treatment for children under 5 is behavioral therapy, not stimulant medication, Caroline Miller https://childmind.org/article/preschoolers-and-adhd/
2) ADHD in preschool children: parent‐rated psychosocial correlates, Nadine A De Wolfe PhD,
Joseph M Byrne PhD, Harry N Bawden PhD; 13 February 2007 https://doi.org/10.1111/j.1469-8749.2000.tb00696.x