[blparent] diagnosing Attention deficit

[Veronica Smith]

Preschool-Age ADHD Children: Too Young for a Diagnosis?
Is a diagnosis or treatment possible for ADHD children under 5? A new study
sheds
light on attention deficit in preschoolers.
by
Arlene Schusteff
A new study, the Preschool ADHD Treatment Study, or PATS, provides insights
about
diagnosing and treating very young children with ADHD.
ADDitude magazine
Friends didn't want their kids to be around our son.
Mary K., mom to Brandon, a preschooler with severe ADD
The Preschool ADHD Treatment Study (PATS): What You Need to Know
Background
Sponsored by the National Institute of Mental Health, and conducted by a
consortium
of researchers at six sites, PATS is the first long-term, comprehensive
study of
treating preschoolers with ADHD. The study included more than 300 three- to
five-year-olds
with severe ADHD (hyperactive/impulsive, inattentive, or combined type).
Most exhibited
a history of early school expulsion and extreme peer rejection.
Stage 1: Parent Training
Ten-week parent training course in behavior modification techniques, such as
offering
consistent praise, ignoring negative behavior, and using time-outs.
Result:
 More than a third of the children (114) were treated successfully with
behavior
modification and did not proceed to the medication stage of the study.
Stage 2: Medication
Children with extreme ADHD symptoms who did not improve with behavior
therapy (189)
participated in a double-blind study comparing low doses of methylphenidate
(Ritalin)
with a placebo.
Result:
 Methylphenidate treatment resulted in significant reduction in ADHD
symptoms, as
measured by standard rating forms and observations at home and at school.
Notable findings
.  Lower doses of medication were required
 to reduce ADHD symptoms in preschoolers, compared to elementary school
children.
.  Eleven percent ultimately stopped treatment
, despite improvements in ADHD symptoms, due to moderate to severe side
effects,
such as appetite reduction, insomnia, and anxiety. Preschoolers appear to be
more
prone to
side effects
 than elementary schoolers.
.  Medication appeared to slow preschooler growth rates.
 Children in the study grew half an inch less and weighed three pounds less
than
expected. A five-year follow-up study is looking at long-term growth rate
changes.
Look for preliminary results in 2009.
Bottom line
Preschoolers with severe ADHD experience marked reduction in symptoms when
treated
with behavior modification only (one third of those in the study) or a
combination
of behavior modification and low doses of methylphenidate (two thirds of
those in
the study). Although medication was found to be generally effective and
safe, close
monitoring for side effects is recommended.
For more information on the Preschool ADHD Treatment Study:
Journal of the American Academy of Child and Adolescent Psychiatry
, November 2006. (
jaacap.com
), National Institute of Mental Health, (
nimh.nih.org
).
Treating ADHD Children
Mary K., of Hillside, New Jersey, suspected that her son, Brandon, should be
diagnosed
with attention deficit disorder (ADD ADHD). At home, life was difficult --
as it
is for many families with
ADHD children
. "Brandon drew on the walls and didn't listen to anything we said. He threw
pictures
or silverware across the room when he was frustrated, which was all the
time. We
lived and died by Brandon's moods. If he was in a good mood, everyone in the
house
was in a good mood, and vice versa. I had a three-year-old running my
household,"
says Mary.
At first, Mary and her husband ascribed Brandon's high activity level to
'boys being boys'
. But when the preschool he attended asked the three-year-old to leave
because of
concerns about his
aggressive and impulsive behaviors
, she began to suspect an ADHD diagnosis was needed.
An elementary school disorder?
After Brandon was asked to leave a second preschool - he'd chased a girl
around the
playground with a plastic knife, saying he would "cut her up" - Mary booked
an appointment
with her son's pediatrician to ask about diagnosing the preschooler with
attention
deficit disorder. Her doctor's response, however, was that Brandon was much
too young
for an ADHD diagnosis. And this response is one that parents of children
with ADHD
across the country in similar circumstances can expect to encounter. Why?
Attention deficit disorder has traditionally been viewed as a disorder of
elementary
school children. While there are hundreds of scientific studies generating a
wealth
of data for diagnosing and treating ADHD in school-age children, there are
few equivalent
studies about diagnosing and treating preschoolers with ADHD. The
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
(DSM-IV)
 criteria used to diagnose ADHD include symptoms such as, "out of seat
during school,"
"does not follow through on instructions," "avoids tasks with sustained
mental effort,"
and "fidgety and restless while sitting"-describing behaviors that may be
developmentally
appropriate for some preschoolers.
Diagnosing ADHD in preschoolers
Is it possible, then, to diagnose children with attention deficit disorder
when impulsivity,
opposition, and extreme activity are normal preschool behaviors? Yes, but
the tipping
point in diagnosis is usually a matter of degree. "Children with ADHD are
much more
extreme than the average three-year-old," says Alan Rosenblatt, M.D., a
specialist
in neurodevelopmental pediatrics. "It's not just that a child with ADD can't
sit
still. It's that he can't focus on any activity, even one that's
pleasurable, for
any length of time."
Larry Silver, M.D., a psychiatrist at Georgetown University School of
Medicine, says
that an experienced teacher, one with a baseline of appropriate
three-year-old behavior,
can be a tremendous help. "You have to look at whether or not the behaviors
are consistent
in more than one environment," he notes.
But experts caution that, even with "red flags," early diagnosis of ADHD can
be difficult.
"You have to delve deep into the root of certain behaviors," says Silver. "A
child
might have separation anxiety, his fine motor skills or
sensory problems
 could be making it hard for him to behave, or it could be evolving
Pervasive Developmental
Disorder," he says.
Nonetheless, Laurence Greenhill, M.D., of Columbia University/New York State
Psychiatric
Institute, points to two behavioral patterns that often predict ADHD
diagnosis later
in life. The first, preschool expulsion, is usually caused by aggressive
behavior,
refusal to participate in school activities, and failure to respect other
children's
property or boundaries. The second, peer rejection, is one that parents can
easily
identify. Children with extreme behaviors are avoided by their classmates,
shunned
on the playground. Other children are "busy" whenever parents try to
arrange playdates
.
In these extreme cases, parents should take their preschooler to
a pediatrician or a child psychiatrist
. Diagnosis of ADHD should involve a thorough medical and developmental
history,
observation of social and emotional circumstances at home, and feedback from
teachers
and health professionals who have contact with the child. In many cases,
neuropsychological
testing may be needed to rule out
conditions whose symptoms might overlap with ADHD
, including anxiety disorder, language-processing disorders,
oppositional-defiant
disorders, and sensory integration problems.
Treatment options
If your preschool child is diagnosed with ADHD, what is the next step? Both
the
American Psychological Association
 and the
American Academy of Child and Adolescent Psychiatry
 advise that ADHD treatment in children proceed according to the severity of
the
symptoms. For
children who play well
 with others and who have healthy self-esteem, Carol Brady, Ph.D., a child
psychologist
in Houston, says that environmental changes can help. "A smaller classroom,
with
less stimulation, and a strong routine often make a tremendous difference in
improving
ADHD symptoms in preschoolers."
In most cases, parent effectiveness training or
behavior therapy
 is the next course of action (see sidebar, at left,
The Preschool ADHD Treatment Study (PATS)
). There is increasing evidence that treating ADHD symptoms in preschoolers
can be
extremely effective, even for children with a high degree of impairment. But
what
if your child with ADHD doesn't respond to behavioral interventions? Is ADHD
medication
the answer? Methylphenidate (brand names include Ritalin and Concerta) is
the most
commonly prescribed medication to treat children diagnosed with ADHD, but it
is not
approved by the Food and Drug Administration for use in children younger
than six.
The Preschool ADHD Treatment Study, or PATS, conducted by the National
Institute
of Mental Health (NIMH), is the first long-term study designed to evaluate
the effectiveness
of treating preschoolers with ADHD with behavioral therapy, and then, in
some cases,
methylphenidate. In the first stage, the children (303 preschoolers with
severe ADHD,
between the ages of three and five) and their parents participated in a
10-week behavioral
therapy course. For one third of the children, ADHD symptoms improved so
dramatically
with behavior therapy alone that they did not progress to the ADHD
medication phase
of the study.
Preliminary data were released in late 2006. "PATS provides us with the best
information
to date about treating very young children diagnosed with ADHD," says NIMH
director
Thomas R. Insel, M.D. "The results show that preschoolers may benefit from
low doses
of medication, when closely monitored."
This article comes from the August/September issue of ADDitude.
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