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Treatment strategies for ADHD in preschool and school-age children

Sonnack, Maria; Brenneman, Anthony MPAS, PA-C

Journal of the American Academy of PAs: October 2014 - Volume 27 - Issue 10 - p 22–26
doi: 10.1097/01.JAA.0000453859.08958.31
CME: Mental Health
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ABSTRACT This review presents current best-evidence treatment options for children with attention-deficit hyperactivity disorder (ADHD), including a review of current literature on the efficacy and safety of psychostimulant medications, particularly methylphenidate, used in treating preschoolers and school-age children with ADHD.

Maria Sonnack is a student in the PA program at the University of Iowa's Carver College of Medicine in Iowa City, Iowa. Anthony Brenneman is director of the PA program at the University of Iowa. The authors have disclosed no potential conflicts of interest, financial or otherwise.

Earn Category I CME Credit by reading both CME articles in this issue, reviewing the post-test, then taking the online test at http://cme.aapa.org. Successful completion is defined as a cumulative score of at least 70% correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME credit by the AAPA. The term of approval is for 1 year from the publication date of October 2014.

FIGURE

FIGURE

The increasing number of children being diagnosed with attention-deficit hyperactivity disorder (ADHD) has been a topic of hot debate among healthcare providers and the community in recent years. Due to shortages of psychiatrists, as well as other factors, many parents rely on their primary care providers to provide ADHD treatment for their children. Because ADHD is within the scope of psychiatry and behavioral medicine, many primary care providers may feel uncomfortable diagnosing and treating it. However, the increased diagnoses of ADHD in children and provider shortage mean that primary care providers, including physician assistants (PAs), must understand current best treatment guidelines for this common childhood psychiatric condition. For clarification, this paper analyzes literature focused on children ages 3-5 years as preschoolers and children ages 6-12 as school-age children.1

Box 1

Box 1

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EPIDEMIOLOGY

According to the CDC, 5.2 million children ages 3 to 17 years (about 8.4%) have ever been diagnosed with ADHD.2 About 12% of boys have ever been diagnosed with ADHD, compared with 4.7% of girls.2 The number of boys diagnosed with ADHD is continually rising, leading community members and healthcare providers to ask if this increase is due to a true presence of ADHD, or whether young, hyperactive, “typical” boys are being incorrectly diagnosed. Scott Lilienfeld and Hal Arkowitz make a good point in their article, Are Doctors Diagnosing Too Many Kids with ADHD, that although the data demonstrate a possible overdiagnosis of ADHD in children, especially in boys, undertreatment of ADHD may be a bigger problem than overtreatment.3 Lilienfeld and Arkowitz are not the only ones to bring this issue to light. Jensen and colleagues also indicate in their article that data exist suggesting that physicians in the community tend to use lower-than-optimal doses in treating ADHD in children.4 Also according to Jensen and colleagues, “providers and parents alike may be sometimes afraid of the medication and too often settle for a less than complete response.”4 Based on this information, providers not only must understand how to properly diagnose ADHD in children and adolescents, but also how to appropriately treat it.

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DIAGNOSIS

According to the American Academy of Pediatrics (AAP), primary care providers should evaluate for ADHD in any child ages 4 through 18 years who has academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.5 The AAP's clinical practice guideline on ADHD recommends using the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) to make the diagnosis of ADHD.6 This includes documenting impairment in more than one major setting. Information needed to make the diagnosis should come from a mix of reports from parents or guardians, teachers, and other school and mental health clinicians involved in the child's care.5 Resources for clinicians, patients, and families can be found at http://www.aap.org.

Box 2

Box 2

Other diagnoses also need to be ruled out. ADHD is the most commonly diagnosed psychiatric condition in children.4,7 Most children with ADHD also have other psychiatric conditions, including oppositional defiant disorder (54% to 84% of patients), conduct disorder, substance abuse disorders (15% to 19%), mood disorders (33%), coexisting learning or language problems (25% to 35%), and anxiety disorders (up to 33%).8-13 According to the DSM-5, a differential list of the following should be considered in making the diagnosis of ADHD: oppositional defiant disorder, intermittent explosive disorder, other neurodevelopmental disorders, specific learning disorder, intellectual developmental disorder, autism spectrum disorder, reactive attachment disorder, anxiety disorders, depressive disorders, bipolar disorder, disruptive mood dysregulation disorder, substance abuse disorders, personality disorders, psychotic disorders, medication-induced symptoms of ADHD, and neurocognitive disorders.6 Current evidence suggests that the main cause of ADHD is genetic.14

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TREATMENT

The use of psychostimulant medications such as methylphenidate in preschoolers is a topic of concern for providers and parents. Although the DSM-5 does not cite developmentally adjusted ADHD criteria for diagnosis of the disorder in preschoolers, current surveys report that 2% to 6% of preschoolers meet full criteria for ADHD.15-17 According to Greenhill and colleagues, due to the lack of appropriate criteria for diagnosis of ADHD in preschoolers, efforts among the psychiatric community have focused on redefining the current diagnostic criteria, such as the Preschool Age Psychiatric Assessment (PAPA), for children in this age group.18 Because of the large prevalence of behavioral problems and associated comorbidities within this age group, criteria must be redefined to avoid overdiagnosis and to assure proper identification and treatment of those who need it.

Preschoolers with ADHD are more frequently suspended from preschool and/or daycare due to disruptive behavior, more frequently suffer from academic impairment, and are more frequently placed in special education programs than same-aged controls.19-21 Preschoolers with ADHD also have an increased incidence of comorbidities, as well as increased rates of developmental delays, language problems, and high rates of underachievement in reading and math.20,22,23 For this reason, clinicians must appropriately diagnose and effectively treat ADHD in this age group.

The American Academy of Child and Adolescent Psychiatry (AACAP) recently released updated recommendations for assessing and treating children and adolescents with ADHD (Table 1). Because these recommendations do not specifically cover preschoolers, we will present current best evidence for treatment of ADHD in this age group. Interventions accepted for the treatment of ADHD in preschoolers are parent behavior training, psychopharmacologic medications (including psychostimulant and nonstimulant medication), and community care.

Table 1

Table 1

Psychostimulants have long been the gold standard of treatment of ADHD in children and adolescents. However, because very little research has been done to examine the implications of these drugs in the preschoolers, the FDA does not recommend their use as first-line therapy in children under age 6 years. Based on a review of current literature, parent behavior training has been suggested as first-line therapy for treatment of ADHD in at-risk preschoolers.4,7,24 Doses for psychostimulants to treat ADHD should be titrated according to patient response to the medication, and not to a specific goal dose or specific dose for weight. Start low, and titrate up slowly until a therapeutic response has been achieved.

Parent behavior training teaches parents how to best manage problem behaviors in their children, with a focus on effective discipline strategies that use rewards and nonpunitive consequences, and promote a healthy, positive relationship between parent and child.7 Commonly used programs include the Positive Parenting Program, Incredible Years Parenting Program, Parent-Child Interaction Therapy, and the New Forest Parenting Program.7 Parent behavior training programs have been shown to reduce disruptive behaviors in preschoolers, including ADHD behavioral symptoms, as well as increase confidence in parenting skills among parents of these children.7 A significant reason for failure of these programs is lack of adherence to completion of the recommended number of sessions.7

Several sources recommend psychostimulants, such as methylphenidate, as second-line treatment of ADHD in preschoolers.5,7,18,24,25 The Preschool ADHD Treatment Study (PATS) is being used widely as current best evidence on the efficacy and safety of these drugs in preschoolers. PATS demonstrated that treatment with methylphenidate significantly reduced ADHD symptom scores compared to placebo (P<0.001 during the titration phase, and P<0.02 during the active phase).24 According to PATS, five adverse reactions occurred more often with higher doses of methylphenidate when compared with lower doses and placebo: loss of appetite, difficulty sleeping, upset stomach, social withdrawal, and lethargy.24,25 Preschoolers taking methylphenidate also seemed to have higher rates of emotional lability than their older counterparts.24,25 In their research on the safety and tolerability of methylphenidate in preschoolers, Wigal and colleagues reported that certain adverse reactions (including irritability, tearfulness, sadness/depression, and listlessness/tiredness) decreased over the 10 months of maintenance treatment, which suggests tolerance of these adverse reactions.25

The PATS researchers reported only one serious adverse reaction—a possible seizure—that may have been related to the use of methylphenidate.24 Although many providers have been concerned about cardiovascular effects of psychostimulant drugs in children of all ages, Wigal and colleagues reported no cardiovascular adverse reactions in their study.25 Although the data reported in PATS showed significant reductions in ADHD symptoms among participants, the degree of effect with use of methylphenidate in preschoolers in this study was lower than what was reported in the Multimodal Treatment Study of Children with ADHD, which studied children ages 6-12 years.24 Rating attention in preschoolers presents a special difficulty because most preschool settings emphasize socialization with others more than performing cognitive tasks.24

Swanson and colleagues studied the effects of psychostimulants on growth rates in small children.26 They found that participants in the PATS study had height gains about 20% less than expected, and weight gains about 55% less than expected. These differences were consistent with observed reductions in the participants' older counterparts in the Multimodal Treatment Study of Children with ADHD.26 Pliszka and colleagues, who also studied growth issues in children with ADHD treated with psychostimulants, recommend three to four assessments of growth each year as being sufficient monitoring of growth in children treated with psychostimulants such as methylphenidate.26,27 The general consensus is that psychostimulants are relatively safe and generally well tolerated as ADHD treatment for preschoolers.24-26,28-35

Treatment of ADHD in school-age children (ages 6 to 12 years) follows the accepted gold standard treatment with psychostimulant medications such as methylphenidate. The Multimodal Treatment Study of Children with ADHD is respected by many in the area of child psychiatry as current best evident treatment for school-age children with ADHD. That study compared treatment with medication, psychosocial treatment, combined treatment, and community-treatment/assessment and referral.36 The results favored psychostimulant treatment alone or in combination with behavioral therapy for treatment of core ADHD symptoms, over other treatments.36 The researchers reported that lower doses of psychostimulant medication were needed when these drugs were used in combination with behavioral therapy, compared with using psychostimulants alone.36

The study also noted important implications of the similarity in effectiveness of medical management alone versus in combination with behavioral therapy in children with co-occurring disorders, and those with fewer resources at home, who may benefit more from combination treatment.36,37 These results also may have important implications for public health because lower psychostimulant dosages are needed for treatment of core ADHD symptoms when medical management is used in combination with behavioral therapy.36

At 3- and 8-year follow-up, the Multimodal Treatment Study of Children with ADHD showed a similar superior effectiveness of psychostimulant medication use and combination treatment in comparison to other cited treatments. However, in the original study as well as the follow-ups, all of the treatment groups showed an improvement in core ADHD symptoms over baseline.38,39 Although therapies including medical management appear to be superior to other treatments in core symptom reduction, no significant differences have been observed between any treatment groups in regards to oppositional/aggressive behaviors, social skills, parent-child relations, and academic achievement.4

Jensen and colleagues, writing about the implications of the Multimodal Treatment Study of Children with ADHD for primary care providers, noted that the study's results suggest that primary care providers “tend to use lower than optimal doses and twice daily, rather than three times daily, dosing.”4 A considerable difference between the medication monitoring for the medical management/combination therapy groups in the study and the community care groups is that the pharmacotherapists in the study used monthly medication monitoring with follow-up visits compared with the standard twice-yearly primary care provider visits in the community.4 The authors make a valid point in noting that this twice-yearly approach may lead to higher levels of nonadherence among patients and caregivers, as well as less than optimal treatment of core symptoms due to under- or overdosing.4 Jensen and colleagues also noted that children with common comorbidities, such as anxiety and oppositional defiant disorder, may benefit from medical management, and behavioral therapy alone may actually be contraindicated in these patients.4

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CONCLUSION

According to current guidelines and recent studies, ADHD in children should first be treated with a psychostimulant medication such as methylphenidate. However, current guidelines suggest that preschoolers should begin with behavioral therapy, followed by psychostimulant medications. PATS demonstrated that psychostimulants are safe to use in preschoolers, but should be used cautiously because of this age group's increased sensitivity to adverse reactions such as irritability, tiredness, and decreased appetite.

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      Keywords:

      attention-deficit hyperactivity disorder (ADHD); children; psychostimulants; methylphenidate; growth; behavioral therapy

      © 2014 American Academy of Physician Assistants.