Departments: Ask the Experts
Brown, Lawrence W. MD
Lawrence W. Brown, MD, Fellow of the American Academy of Neurology, is an associate professor of neurology and pediatrics and director of the pediatric neuropsychiatry program at Children's Hospital of Philadelphia. Dr. Brown also served on the committee that reviewed the scientific evidence for the American Academy of Pediatrics guideline.
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Your Questions Answered
QI saw an article in the paper about ADHD drugs being given to toddlers. Is this too young? How does a neurologist decide whether to give a drug for ADHD?
DR. LAWRENCE W. BROWN RESPONDS:
A In some cases, drugs for attention deficit hyperactivity disorder (ADHD) may be prescribed to toddlers. However, neurologists and other specialists do not take the idea of putting young children on medication lightly.
The most recent guideline published by the American Academy of Pediatrics states that parent- and/or teacher-based behavioral support should always be the first approach in all pre-school children with such attention and hyperactivity issues.
The report goes on to say that the treating doctor may prescribe stimulants—the most commonly prescribed medications for ADHD—if behavioral interventions do not provide significant improvement and the child continues to show moderate to severe disturbance in function. The clinician will then need to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment.
ADHD involves a broad range of behavioral problems, such as difficulty sustaining attention, hyperactivity, and trouble with impulse control. Even at a very young age, some children with these challenges require intervention to help them to function.
The difficulty with identifying these behaviors in young children is that not all children develop in the same way or at the same rate. The challenge is discerning what may be developmental—and perhaps a passing phase—from a behavior that is so problematic that it needs intervention. It is hard to know at which point impulsive aggression, daredevil behavior, or short attention span for the age and developmental level is sufficiently problematic to be classified as ADHD and treated with either medication or behavioral therapies. If children are at risk of harming themselves or others, or are already being asked to leave daycare or other activities, they are likely at risk and need guidance from a trained professional.
Some of the behaviors associated with ADHD may also be caused by other conditions, such as autism, global developmental delay, anemia, and hyperthyroidism, inadequate sleep, or even unstructured and unsafe environments.
Behavioral support can include different types of therapy such as behavioral modification programs, in which the child, parents, teachers, and family all participate in fostering more effective behaviors in the child; cognitive behavioral therapy, in which the child is taught to better understand how thoughts and feelings affect behavior; other treatment with a trained therapist; and treatment specifically to improve social skills.
An overview of the guideline from the American Academy of Pediatrics is available at bit.ly/AAP-ADHD. Also, see Neurology Now's “Ask the Experts” response on non-pharmacological treatment for ADHD in children here: bit.ly/ADHD-nn.