Applying Psychological Science, Benefiting Society

ADHD in Preschoolers: Overmedicated and Undertreated

Young boy with sad expression

Doug Tynan, PhD (Director, Integrated Healthcare, APA Center for Psychology and Health)

An estimated 194,000 toddlers and preschoolers (age 2-5 years) in the United States have been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and about 1 in 2 of them is not receiving the recommended treatment according to the Centers for Disease Control and Prevention. Yes, that is correct – about half of the young children diagnosed with ADHD are not receiving the appropriate treatment.

Since 2011, the treatment guidelines from the American Academy of Pediatrics have recommended that preschoolers diagnosed with ADHD receive behavioral therapy first before medication. But, almost 50% of diagnosed preschoolers received no behavioral therapy. Too many are being treated with stimulants and other psychoactive medications as the sole form of treatment.

This is a serious problem for four reasons:

  1. There are no valid diagnostic criteria for ADHD for children in this age range.
  1. Two- and three- year-olds are by nature hyperactive and often non-compliant. Child activity level essentially is at its highest from two to four and then decreases over the years, so children are at their most active phase of life in those years. Along with that fact, children of this age range have not developed the ability to put on the brakes, follow directions, and easily comply with rules. Now many parents of children diagnosed with ADHD at age 7 say that they knew their child was hyperactive at age two. This may be true. However, for every four or five children who appear to be hyperactive at age two the majority will be within normal limits by age 7. You cannot predict which child will be clinically hyperactive by school age. 
  1. There is very little research on the impact of psychoactive medicines, particularly the stimulants, on very young children. The few studies that have been done have shown that the medicines are not very effective in this age range, have a much higher rate of side effects including appetite suppression, irritability and sleep disruption, and generally just don’t work that well.
  1. There are effective treatments out there to help these children and families. Systematically teaching parents to improve their behavior management skills, build in healthy routines for meals and sleep and moderate their own responses to their child’s behavior have shown to be remarkably effective. There are a group of programs that work including Triple P Parenting, the Incredible Years Program, and Parent Child Interaction Therapy. Referral for a family to the appropriate trained therapist is the best solution. The problem is families often don’t get linked to the right therapist. Another problem is that these programs are expensive in their training, often beyond the means of stressed budgets at mental health agencies.

But there is good news to help both children, parents, and therapists. Over the past several years, the CDC’s National Center for Injury Prevention and Control has analyzed all of the effective therapy programs, determined what makes them effective, and identified their common features. What Jennifer Kaminsky, PhD, found is that increasing positive parent-child interactions and learning to effectively discipline without resorting to spanking were two of the most important elements. The other two are teaching effective communication skills as well as use of social praise and rewards. Based on the existing research and this analysis, the CDC recently released a set of videos and other materials to teach these effective parenting skills on a new website: Essentials for Parenting.

So now, parents have a free effective option to choose when they find that their child is overly active and hard to manage. Therapists and pediatricians also have additional materials to use to help families. And perhaps, we can finally dispense the notion that one can diagnose a child with ADHD at age two and help parents by doing something that is effective with no side effects.

For more info, check out the CDC’s handy infographic on ADHD treatments for preschoolers.

Infographic ADHD in preschoolers

Biography:

Board Certified in Clinical Child & Adolescent Psychology and Health Psychology, Dr. Tynan has had a long career in education and psychology, starting out as a special education teacher at a school and summer camp program for children with autism.  Following graduate school at Binghamton University, he went on to develop team programs at Cumberland Hospital, a children’s rehabilitation hospital, then a second program at Children’s National Medical Center to reduce re-admissions for children with Type I diabetes,  He went on to develop co-located health and mental health programs in pediatric clinics in medically underserved areas in Delaware.  He also implemented effective evidence-based group programs for parents and children with ADHD and oppositional defiant behaviors that have been successfully used for over 25 years.  He has served as a consultant for Head Start on a national level.  A Professor of Pediatrics at Jefferson Medical College, his interests are primarily in the coordination of health, mental health, education and social services to serve families more effectively and efficiently to address the needs of patients of all ages. Dr. Tynan also currently serves as Director of Integrated Health Care in the American Psychological Association’s Center for Psychology and Health.

Image source: Flickr user Jessica Lucia via Creative Commons

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12 Responses »

  1. As a family case manager I’ve found that parents often become frustrated with the number of roadblocks they come across in accessing therapeutic resources and appropriate behavior interventions. Like the article mentions, many mental health agencies are under funded and maxed out at the number of patients they can accept, so many times clients are placed on months-long waitlists and then placed with exhausted/overworked/underpaid therapists. Furthermore, children with multiple diagnoses often don’t fit the eligibility requirements of some programs – kids that have ADD may also have trauma related disorders, FAS, or disorder attachment and are often left with fewer options for treatment and even longer waitlists. Not to mention, payment barriers and how insurance fails us in the mental health arena. A Doc prescribing meds is often the quickest way an overwhelmed parent can handle this kind of situation, which is disheartening to say the least.

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    • While I’d be the last person to minimize the important of parental training around ADHD, I’ll also point out that medication has been shown the most effective intervention. Time and again.

      More important than “therapy” for the child is screening the parents for ADHD>>

      Studies have shown that adult ADHD adversely affects parenting skills. And no amount of “parenting therapy” improves the parenting skills of parents whose significant ADHD symptoms go untreated medically.

      Those are the facts.

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  2. i did not realize this until now when i read this.it was kind of supirizing to find this out.

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  3. Very Interesting and glad to know about after go through.

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  4. As a clinician I find that parents often bring their preschool children to the doctor and/or mental health provider such as myself when the babysitter, day care provider or preschool has indicated that the behaviors interfere with the classroom and the child is at risk to being “kicked out”. The parent, who needs the early childhood services due to their job, is anxious to find a quick fix. There are no quick fixes unfortunately however medication may be perceived to be the quicker fix and therefore keep the child in out of home early childhood care. It is a difficult situation for the parents and they often feel caught in the middle.

    Along this same line of thinking, with the increased demands for academic achievement at the kindergarten level, again parents are being urged to consider treatment (often in the form of medication) as an educator might believe that medication might help the child “focus and learn”. My review of the literature indicates that stimulant medication doesn’t necessarily increase the ability to learn, however educators might believe otherwise.

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    • Stimulant medication can normalize ADHD symptoms, allowing a student to pay attention, read with comprehension and retention, etc.

      The studies you refer to are probably those conducted by economists, and they are highly problematic, for a host of reasons.

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  5. Guess what, folks?

    For those of you who don’t have a medical degree or life-science advanced degree, I have some news for you.

    Despite what the CDC implies here, ADHD is often a medical disorder with medical implications.

    Many of these young kids on Rx suffer the most severe symptoms, and they suffer other several neurological disorders, such as spina bifida.

    This is a complex story, and it serves no one to pander to public ignorance.

    It is especially wrong-headed for psychologists to reinforce public perceptions that ADHD is all about “unruly behavior” and being “hard to manage.”

    Sleep disorders, eating disorders, asthma, allergies, and a host of other medical conditions are associated with ADHD.

    You can read more here: http://wp.me/p5Ilzb-Uc

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    • Response on behalf of blog post author – Doug Tynan, PhD (Director, Integrated Healthcare, APA Center for Psychology and Health):

      The blog post focuses on the use of medication in preschool age children (ages 2-5) and not adults. Both the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry agree that medication should never be the first line of treatment. In young children, many factors can trigger inattention and hyperactivity, including poor sleep, traumatic stress and other medical, developmental, educational and environmental issues. Further, researchers in the area of ADHD brain development over time, such as Jay Giedd, Xavier Castellanos and Russ Barkley have shown that the midbrain and frontal lobe develop more slowly in children in ADHD. Indeed, they develop in many children on a different time frame. This would explain why nearly half of children with ADHD do not grow up to be adults with ADHD. You have to assess ADHD at each age. While some people do have ADHD through the lifespan, the data would suggest it is not necessarily a lifelong condition for everyone.

      The data on medication treatment for preschoolers is clear, it rarely works and has severe side effects. In the only major study published on preschool treatment, only 4% of the children with ADHD were still taking medicine after a year. Most dropped out due to severe side effects of appetite loss, abdominal pain, headache, loss of sleep and irritability. After more than 40 years in the child serving professions, having run an ADHD clinic at major children’s hospital, and having successfully published outcome data from parenting programs that show we can help parents to positively influence their children’s development of self-control, and as the parent of a child diagnosed with ADHD, I have to respectfully disagree with your comments.

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      • But what do you “respectfully disagree with,” specifically? And can you substantiate your disagreement? You’ve missed my points.

        1. I wasn’t speaking of adults, but children.

        2. You are still apparently viewing ADHD as solely a “behavioral” issue and not a medical condition, which is is for many children—including sleep disorders, enuresis, encopresis, asthma. This is backed up in the literature. Anecdotally, there are young children with ADHD-related eating disorders, including lack of interest in food.

        Michael J. Manos, PhD, who heads the Center for Pediatric Behavioral Health at The Cleveland Clinic and has an impressive record of research cites this study:

        “One study of children age 3 and younger in the Michigan Medicaid system found that 44% had problems that coexisted with ADHD, 41% had chronic health conditions, and 40% experienced other injuries.”

        Clearly, “behavior therapy” and “parenting therapy” is not going to help many aspects of these children’s symptoms. Perhaps some of these physicians know more than psychologists who have no expertise in physiology.

        2. Barkley’s longitudinal research show that up to 90 percent of children with ADHD do NOT outgrow it. Much depends on the presence or absence of independent reports.

        3. No, the data on Rx and pre-schoolers is not “clear.” It is very mixed, and of course much depends on accurate diagnosis and presence or absence of pre-existing conditions.

        Generally, psychiatrists and GPs are doing an abysmally poor job with adults, teens, and older children; I can’t imagine why it would be any better with very young children, who cannot verbalize their complaints.

        (Let’s leave aside for the moment that our healthcare system is routinely inept in identifying other conditions—food sensitivites, allergies, nutritional deficiencies, and the like.)

        As Dr. Manos states (excerpted in the blog link I posted above):

        “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.”

        4. You use unrelated data (that is, research not done on children with ADHD) to say that these parenting techniques will work for children with ADHD, and you assume that it’s an “unruly behavior” problem. I’m informing you that there is much more than “behavior” at stake with ADHD; there are physical symptoms.

        And you make no mention of screening parents for ADHD, despite research showing that parenting training is ineffective in parents whose own ADHD remains poorly addressed.

        My point: These issues are highly complex. The CDC numbers are estimates, based on what I consider very problematic collection methods. (Doubt me? Read the survey’s limitations.)

        We have enough scare stories from the “news outlets” and anti-psychiatry blogosphere. We don’t need APA-produced scare stories, which miss all the nuances of this highly complex issue, muddying the waters further in the public’s mind.

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  1. ADHD in Preschoolers: Overmedicated and Undertreated | Dr. Delight, PA
  2. ADHD in Preschoolers: Overmedicated and Undertreated - Psych Learning Curve

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