ADHD medication: How young is too young?
Stimulant medication management of attention-deficit/hyperactivity disorder in children as young as age 4 years is a problem faced by many physicians. While treating young children remains poorly understood, it has become more widely practiced in recent years. Currently, the practice is hampered by scant clinical studies on the effects of stimulants on preschoolers, as well as varying degrees of patient response and the chance of unforeseen behavioral and cognitive side effects.
Read comment from an expert whom Infectious Diseases in Children asked for her opinion on whether pharmacological intervention should be recommended to children aged younger than 4 years, and if the benefit of treatment significantly improves the quality of life for the child and the family.
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Joyce Nolan Harrison, MD
Maryland Behavioral Health Integration in Pediatric Primary Care
Member, AACAP Committee on Infant and Preschool Psychiatry
Assistant professor, department of psychiatry
Johns Hopkins University School of Medicine
A recent review of Medicaid data from 36 states reported that 1% to 2% of children aged younger than 4 years are receiving psychotropic medication, with 61% of those for ADHD. A New York Times article from May 2014 reported that, according to data from the CDC, more than 10,000 American toddlers aged younger than 4 years are being medicated for ADHD.
Despite the fact that the most recent AAP guidelines for ADHD treatment are restricted to patients aged 4 to 18 years, the vast majority of prescriptions for children aged younger than 4 years are written by primary care providers.
The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that, for children of any age, a diagnostic assessment and a trial of psychotherapy precede a medication trial, whenever possible. An AACAP workgroup on preschool psychopharmacology published guidelines specific to the use of medication in children aged 0 to 5 years. There are considerable diagnostic and treatment challenges for children aged younger than 4 years.
Preschoolers present with a limited repertoire of behavioral difficulties, including tantrums, aggression, impulsivity, and hyperactivity. In a brief primary care visit, or by parent report and screening, these very young children may appear to meet criteria for ADHD but are not yet in an educational setting where the diagnosis can be confirmed or ruled out.
In a psychiatric setting, comprehensive assessment requires multiple visits, multiple informants — such as family, pediatrician or day care provider — and often results in referral for other assessments such as for speech and language, cognitive or developmental difficulties. These nonpsychiatric factors often underlie behaviors that overlap with ADHD; failure to address these other issues and use only a medication intervention could negatively impact the child’s optimal developmental trajectory. Even if the diagnosis of ADHD is made, there is limited access to mental health clinicians skilled in both pharmacologic and nonpharmacologic interventions for this age group. The majority of child psychiatrists receive little training in the treatment of very young children, and many are not comfortable medicating children aged younger than 4 years.
Child psychiatry access programs such as our Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP) program, funded by the Department of Health and Mental Hygiene and for a time by the federal Race to the Top Early Learning program, have begun to address this need. A team, which includes child psychiatrists, a developmental pediatrician and therapists, provides telephone consultation and training to primary care providers in early childhood mental health. A resource team connects the primary care providers to local early childhood clinicians and services.
Preschoolers have the highest rates of child care/school expulsion of any age group and are presenting to pediatric primary care providers in increasing numbers. Medication for preschoolers who truly have ADHD can be extremely beneficial and make a dramatic impact on school readiness. We have strong evidence from the literature and clinical experience about its safety and efficacy in children aged younger than 4 years.
However, medication must be considered carefully, and only in the context of a clear diagnosis, with attention to nonpsychiatric comorbidity, and after the failure of other interventions.
Disclosure: Harrison reports that the BHIPP project is supported by the Maryland Department of Health and Mental Hygiene grant number 16-14685G. Maryland BHIPP is a collaboration among the University of Maryland School of Medicine, Johns Hopkins Bloomberg School of Public Health and Salisbury University.