ADHD in Preschoolers: Consensus or Controversy?

Since the American Academy of Pediatrics (AAP) released practice guidelines on the diagnosis and management of attention-deficit hyperactivity disorder (ADHD) in 2011, there have been many opinions bandied around. There was worry that ADHD would be inappropriately diagnosed at such early ages. A parallel concern was that preschoolers would be put on pharmacological regimens too quickly. Conversely, others argued that the roots of clinically significant ADHD are visible in the preschool years, and early identification and intervention would help derail a trajectory of increasing symptom severity and impairment – educational as well as social – in later childhood and beyond.

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Where do we stand now? Recent studies are beginning to paint a picture of the utility of diagnosing ADHD in preschoolers along with emerging pitfalls. Here we focus on the two issues raised in the 2011 AAP guidelines: the risk for over-diagnosis, and the risk for over medicating preschoolers (as the guidelines suggested that behavioral interventions should be the first line of treatment, not pharmacological approaches).

First, we turn to the issue of diagnosis.

Two general principles about ADHD that go beyond developmental staging should be considered. Trained experts who utilize the most sophisticated and well-studied assessment tools are typically very reliable diagnosticians. They can discriminate, with reasonable certainty, when a child is showing significant symptoms – the type that are associated with compromised functioning at home, in school, and on the playground – versus age-normative levels. Individuals with insufficient training and expertise are more prone to rely on less sensitive diagnostic tools and to over-diagnose.

Do these principles apply to ADHD in preschoolers? Yes. Relying only on questionnaires administered to parents and teachers to gather information on number and severity of symptoms is limited. This isn’t to say that the resultant data are not of use; rather the data are most effective as part of the diagnostic process. More sensitive and reliable diagnoses are obtained when additional methods are used that permit clinicians to learn more about each child’s level of symptoms. For example, a recent study has shown that usage of the Diagnostic Interview Schedule for Children (DISC-IV) – a tool that allows clinicians to ask structured questions that probe for clinically relevant symptoms – yields reliable diagnoses. Furthermore, the information obtained using the DISC-IV offered additional prediction of future problem behavior, beyond that offered by using only the rating scales. Thus, well-qualified clinicians using the best available tools can provide reliable and valid diagnostic screening of preschoolers.

Next, we turn to the treatment issue.

There is evidence that the introduction of the 2011 AAP practice guidelines has not resulted in increases in pharmacological treatment. A review of electronic health record data, obtained from 63 primary care practices, concluded that the rate of prescribed medication prescribed for ADHD in preschoolers remained stable after the introduction of the guidelines. However, another recent study surveyed over 300 board-certified child and adolescent psychiatrists and found that only 7.4 percent reported following the AAP guidelines of using behavioral management as the first treatment of choice, followed by pharmacotherapy. Thus we see reports of both adherence to, and lack of adherence to, the AAP guidelines when it comes to treatment.

What, then, should you make of this? There are two solid takeaways.

First, a preschooler who is suspected of suffering from ADHD should be evaluated using the most comprehensive and researched diagnostic tools. Simply gathering data from questionnaires does not constitute a sufficient clinical review, which would involve standardized interviewing and other forms of assessment as deemed necessary. Without such due diligence, it is not possible to come to a diagnosis.

Second, preschoolers who receive a well-substantiated diagnosis of ADHD should be offered behavioral interventions as a first-line treatment. These should be monitored for compliance and given every opportunity to lead to improvement before considering pharmacotherapy.

While there may be both consensus and controversy about diagnosing ADHD in preschoolers, reliance on these two principles offers the most rationale and supported perspective.