Do you have any suggestions for treating severe ADHD in very young children (ages 2-4)?
Head of the Section of Behavioral Medicine of a State Children's Hospital, explains the dubious American approach that is not allowed in the U.K.
Pharmacotherapy of ADHD in young children is a dilemma faced by many practicing physicians. Treating young children is poorly understood, even though in recent years it is more widely practiced. At present, clinical practice is hampered by the availability of only a limited number of clinical studies on the effects of stimulants on preschoolers. This problem is compounded by the potential for greater variability of response and the possibility of unanticipated behavioral and cognitive side effects, and thus, it is prudent for physicians to be cautious.
Although early treatment of ADHD tends to yield more favorable outcomes, no gold standard has yet emerged for treatment of preschoolers assumed to have ADHD. One study that addresses diagnosis and treatment of preschoolers with ADHD symptoms indicates considerable variability in procedures. Rappley and colleagues[1] identified 223 children 3 years of age or younger who were diagnosed with ADHD in the Michigan Medicaid system between 1995 and 1996. In all, 44% had problems that coexisted with ADHD, 41% had chronic health conditions, and 40% experienced other injuries. Furthermore, 57% of the sample received psychotropic medication with 22 different medications; only about one quarter (27%) received psychological services. The investigators contended that the scarcity of information on the diagnosis of ADHD in preschoolers and the limited information on efficacy and safety of psychotropic medications for this age group created great variability in the medication regimens.
Psychological consultation or parental education is often recommended as the first line of treatment for families with a preschooler diagnosed with ADHD. Despite this cautious approach, recent studies describe increased stimulant prescribing for American and Canadian preschoolers because of the ease of treatment and availability of prescription remedies.[2] An earlier review by Zito and colleagues[3] showed a notable upsurge (between 1.7- and 3.1-fold) in the use of stimulants for preschoolers in state Medicaid programs. One of the primary reasons cited for the growing use of psychotropic interventions was that many physicians realize that psychological interventions are costly and difficult to sustain. Moreover, medication management is more readily available, easier to administer, and produces consistent results.[4] Despite the increasing use of stimulants for preschoolers with ADHD, efficacy and risk research with young children has been sparse and plagued by sample size problems.[5] The paucity of data and lack of guidelines concerning pharmacotherapy effects in children under age 6 years should be ameliorated by the Preschool ADHD Treatment Study headed by Dr. Lawrence Greenhill, which will develop guidelines for patients aged 4-6 years. Until more information is available, however, clinicians must use practiced knowledge.
Diagnosing and Managing Very Young Children
Severe ADHD in children 2-4 years of age is especially problematic. Young children do not have the ability to use or respond to language to moderate behavior that older children have; subsequently, behavioral interventions often have limited effectiveness. Young children may not make associations between instructions and rules and the consequences of violating them; subsequently, hyperactivity and impulsive behavior are relatively immune to psychosocial intervention.
The younger the child, the lower the certainty of an accurate diagnosis of ADHD. It is very difficult, for example, to diagnose ADHD before age 3 years because short attention span, high activity level, and impulsivity are normal temperamental characteristics at various stages of development (eg, consider the "terrible two's" or the "difficult child" syndrome described in the temperament literature). Such symptoms are not normal, however, when they continue to manifest beyond certain ages.
Symptoms most likely to be associated with ADHD at young ages are chronic motor restlessness; noncompliance; vigorous, persistent activity level; and destructive play. Children may require constant parental monitoring because they show excessive emotional outbursts (ie, tantrums) that are intense and frequent. Such children also often have difficulty completing developmental tasks such as toilet training and sleeping in their own beds, and they may demonstrate delays in motor or language development. Such behavior significantly affects family life as parents have difficulty obtaining and keeping babysitters, and a wife and husband may find their relationship with each other faltering given the constant attention to childcare and behavior control.
Even though diagnosis of mental health disorders in early childhood is problematic, the need for effective treatment of young children is critical. Gadow and colleagues[6] noted that preschool children who were "referred for clinical evaluation evidenced higher levels of symptom severity than a community sample, with children with ADHD symptoms more impaired than other children."
In a naturalistic study of a community sample of young children with ADHD, we examined the quality of behavioral response, and we delineated the side-effect profile of 4- to 5-year-old preschoolers naive to previous psychostimulant treatment.[6] Our preschool sample is not unlike children who might present in typical pediatric practice for treatment of symptoms of ADHD.
The study provides support for the short-term efficacy and safety of psychostimulant medications for preschoolers. Behavioral ratings improved for all children across home and school settings, with 82% of the children receiving clinical ratings of normalized behavior on their optimal dose of medication. In addition, undesirable side effects did not differ from the profile one might see in older children (6-12 years). Many parents reported more side effects during the baseline and placebo weeks than during the best dose week. (This result is reported in other studies as well.[7]) Irritability and diminished appetite are often cited as side effects of stimulant use in young children, but it is important to note that irritability also appears to be a by-product of the disorder itself. Baseline data from our sample indicated that over 33% of preschoolers were rated as irritable by their parents before medical management. These reports are consistent with Connor's review[8] in which he argues that preschoolers benefit from stimulants, side effects appear minimal, but great care should be used in the diagnostic process.
Elimination of behavioral symptoms associated with ADHD in young children, then, can be achieved with medication. By improving the behavior of preschoolers, pharmacotherapy enables them to more optimally explore their worlds and take advantage of potentially important learning opportunities.
Proceed With Caution
Regardless of reported efficacy of stimulants in preschoolers, clinicians should still proceed with caution. Little is known about the effects of medicines on the neurochemistry of the brain, especially during periods of formative plasticity in the first 3 years of life. Does stimulant exposure in the first 3 years of life increase dopamine transporter density, thus exacerbating ADHD symptomatology in later years? Are homeostatic properties of the brain disrupted with early exposure to medicine? Given growing evidence, these outcomes are unlikely, but careful diagnosis and comprehensive management strategies are necessary to ensure the well-being of young children.
The guiding question of medication management in young children with severe ADHD is whether or not the benefit of treatment significantly improves the quality of life for the child and the family. A 2-year-old child with severe hyperactivity and chronic impulsive behavior who is shuttled from one foster family to another has a poor prognosis. That same child, treated, may have a chance of stability in the early years.
Although medical management is not a panacea for enabling preschoolers to more effectively control their behavior, it is nevertheless one piece of a comprehensive package that has the potential to improve the cognitive and social outcomes for young children.
IS THIS KIND OF DUBIOUS PRACTICE WHAT WE WANT IN THE U.K.?
NICE GUIDELINES SAY CATEGORICALLY NOT. 
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