The Earlier, the Better: Diagnosing and Treating ADHD in Preschoolers

Vera Joffe, Ph.D. ABPP
www.verajoffe.com

The presence of mental health disorders in preschool children, such as anxiety, depression, bipolar disorder and ADHD has been documented more frequently in the past 10 years (Luby, 2017). However, despite recent evidence that early detection of mental health disorders may help in decreasing the severity and even the development of such conditions, child psychiatrists may not have an opportunity to screen young children for mental health disorders as parents usually do not use the service of these specialists when their children are very young.

Although pediatricians usually screen older children for symptoms of ADHD, parents usually report that pediatricians rarely assess, treat, and refer preschool children for symptoms of mental health disorders. There is evidence that the prevalence of preschool children with ADHD is 2 to 8% (Egger & Angold, 2006).

Longitudinal studies have indicated that when children are not diagnosed and correctly treated with ADHD, they may develop more impairments and comorbid disorders in adolescence and adulthood (Barkley, 2015). Pediatricians are the first professionals who are able to diagnose children with ADHD and comorbid conditions in early childhood.

Why is it important to diagnose children who are showing significant impairments and symptoms of ADHD at such an early age? Because early diagnosis and intervention may lead to more effective, successful and hopefully, shorter treatment. In addition, the brain’s ability to change in response to experiences is much higher in early
childhood (Center on the Developing Child, Harvard University).

1. Preschoolers need to be fully assessed for many areas of functioning, such as emotional, social, cognitive, speech and language, and behavior. It is also important to conduct a behavioral assessment to learn about the environment the child lives in, and to develop a contingency program for a preschooler along with parent education/treatment.
2. Helping parents understand ADHD as an impairing condition and guiding them in developing behavioral strategies and contingency plans that actually may work well for children with symptoms of ADHD may prevent the development of more serious symptoms and impairments even before children enter formal education.
3. It is important to conduct a full assessment with a detailed developmental history, family history, and by using multi-informants and multi-methods to assess ADHD and comorbid conditions in preschool age children. It is recommended to obtain information through questionnaires, such as the Conners parent and teacher rating scales (Conners,2001), or the Child Behavior Checklist (Achenbach & Edelbrock, 1991). It is also important to conduct clinical observations of preschool children at school and in other settings (Luby, J.L., 2017).
4. Empirically-based treatments for ADHD in young children include behavioral and parenting treatment, such as Parent Child Interaction Therapy (Eyberg & Funderburk,
2011), Behavior parent training adapted to preschool population (BPT), and Community Parent Education (COPE).
5. There has been some research to study the contribution of medication in addition to parent-child and parenting interventions (and education), such as the Preschool ADHD Treatment Study (PATS), and the long-term PATS follow-up study. The PATS focused on the effect of one type of medication only (MPH). More recent studies have been completed for this age population. Most studies strongly suggest that one should consider behavioral treatments for preschoolers with ADHD as well as the protocols discussed above before including medication for preschoolers due to the strong side effects of medications for this age population.
6. “The apple does not fall far from the tree”: ADHD is highly genetic, and for this reason, it is important for pediatricians and others working with families with children with ADHD to assess whether parents also show symptoms of ADHD in order to help parents with the same diagnosis so that they can follow through with treatment recommendations for their own children.
7. Thus, it is necessary to provide education to the public in general and to other health care providers (especially pediatricians) about the advantages of diagnosing and treating children with ADHD early in life to help prevent the development of more severe and impairing comorbid conditions.

References:
Achenbach, T.M. & Edelbrock, C.S. (1991). Manual for the Child Behavior Checklist and Revised Child Behavior Profile. Burlington, VT: University Associates in Psychiatry.

Barkley, R. A. (2015). Attention-deficit hyperactivity disorder: A handbook for diagnosis and treatment (4th Edition). New York: Guilford Press.

Center for the Developing Child at Harvard University. https://developingchild.harvard.edu/

Conners, C.K. (2001). Conners’ Rating Scales- Revised: Instruments for use with children and adolescents. North Towanda, NY: Multi-Health Systems.

Egger, H.L. & Angold, A. (2006). Common behavioral and emotional disorders in preschool children: Presentation, nosology, and epidemiology. Journal of Child Psychology and Psychiatry, 47, 313-337.

Eyberg, S.M. & Funderburk, B. (2011). Parent-child interaction therapy protocol. Gainesville, FL: PCIT International.

Luby, J., editor (2017). Handbook of Preschool Mental Health: Development, Disorders, and Treatment. Second edition, New York: The Guilford Press.

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