Attention deficit hyperactivity disorder (ADHD) is a common, yet controversial mental illness. Prevalence rates and medication rates have been steadily increasing since the 1990s, and now children as young as 4 years of age are being diagnosed and treated for ADHD.
What is ADHD?
The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), states that ADHD as a “neurodevelopmental disorder defined by impairing levels of inattention, disorganization, and/or hyperactivity-impulsivity. Inattention and disorganization entail inability to stay on task, seeming not to listen, and losing materials, at levels that are inconsistent with age or developmental level. Hyperactivity-impulsivity entails overactivity, fidgeting, inability to stay seated, intruding into other people’s activities and inability to wait-symptoms. … ” In other words, diagnosis is somewhat subjective and mental health specialists rely heavily on parents’ and teachers’ reports.
In the DSM-5, ADHD symptoms must begin before age 12, but a minimum age for diagnosis is not specified. The American Academy of Pediatrics cites the minimum age at 4 years, even though inattention, hyperactivity and impulsivity are normal in young children. Therefore, the decision to diagnose and treat “symptoms” early is mainly at the discretion of the clinician.
Approximately 11 percent of children between 4 and 17 years of age were diagnosed with ADHD as of 2011, according to the Centers for Disease Control and Prevention (CDC). The average age of diagnosis is 7 years, with more severe cases being diagnosed earlier. As of 2011, about two-thirds of those diagnosed were taking medication.
The controversy over preschool diagnosis of ADHD
A recent article in Psychiatric Times by E. Mark Mahone, Ph.D., stressed early diagnosis and treatment of ADHD as soon as potential symptoms present, based on the established connection between preschool problems and later functional difficulties.
Conversely, other ADHD experts express concern about too many academic demands on children who are not neurologically ready, resulting in overdiagnosis and overmedication of normal kids. One such expert from the University of California at Berkeley is Stephen P. Hinshaw, Ph.D., who promotes caution about overdiagnosis. Hinshaw also points out how parenting mediates inattention symptoms and impairment, supporting parental education and therapy as a treatment modality.
Many scientists and authors emphasize the positive side of ADHD symptoms, such as intelligence, creativity and eagerness. Scott Barry Kaufman, who is the scientific director of the Imagination Institute in the Positive Psychology Center at the University of Pennsylvania, reframes ADHD in a positive light in his article on the creative gifts of ADHD.
Behavioral intervention strategies exist for parents, teachers and children with ADHD. Therapeutic programs can be more costly and time consuming than medication, but they have been shown to improve ADHD symptoms and improve situational factors that exacerbate symptoms.
The World Health Organization recommends parental education and training before starting medication for ADHD as well as cognitive behavioral therapy and social skills training if possible. No data is currently available regarding how many American children currently receive nonpharmacological therapy. Regardless, some alternative strategies include:
Parent and teacher programs: Separate programs teach parents and teachers behavioral strategies, such as positive reinforcement.
Therapeutic recreational programs: These programs provide immersion in recreational and behavioral therapy for groups of children with ADHD in venues such as summer camps.
Neurofeedback: This is a noninvasive form of technology-assisted brain training that helps create new neuropathways and improves volitional control. Whether neurofeedback is useful in children under 5 years of age remains unclear.
Lifestyle changes: Inadequate or inconsistent nutrition, sleep and physical activity exacerbate ADHD symptoms. Regular, healthy daily routines have been shown to mitigate symptoms while creating good habits that last. Various methods of dietary management and exercise programs have been shown to be particularly effective.
Other methods: Behavior modification, multimodal psychosocial treatment, school-based programs and working memory training are some other therapeutic options. When alternative measures fail, occasionally pharmacological therapy is considered for young children.
For various reasons, preschoolers are sometimes treated with medication for ADHD. The long-term neurodevelopmental outcomes of these children are still unknown, but researchers evaluated safety in a study funded by the National Institutes of Health’s National Institute of Mental Health.
The Preschool ADHD Treatment Study, or PATS, was a major study designed to determine the safety and efficacy of methylphenidate (Ritalin) in preschoolers with ADHD. The authors concluded that, overall, low doses of this medication were effective and safe. However, the preschoolers were found to be more sensitive than older children to medication side effects, such as sleep disturbances, so the authors recommended close monitoring. This study was reported in several articles in the November 2006 issue of the Journal of the American Academy of Child & Adolescent Psychiatry.
As more children as young as 4 years of age are diagnosed with ADHD, the validity of diagnosis in preschoolers remains controversial. Collaboration between clinicians, parents and teachers is necessary to ensure accurate diagnosis and therapeutic strategies. The WHO recommends parent/teacher training prior to starting medications. Many other strategies have been shown to improve ADHD symptoms without the use of medication. When medication seems necessary, methylphenidate appears to be effective and safe in small doses and with close monitoring of side effects.
ADHD in the young challenges families and communities to work together to find solutions to this growing problem. At White River Academy, we incorporate multidisciplinary strategies to promote lasting behavioral health in young men ages 12 to 17. For more information, please call our 24/7 helpline.