New Guidelines: Diagnose Kids for ADHD at Age 4

Oct. 17, 2011 -- Attention deficit hyperactivity disorder (ADHD) should be diagnosed and treated in children as young as age 4, according to new guidelines from the American Academy of Pediatrics.

Previous guidelines for pediatricians, issued 10 years ago, had limited the diagnosis and treatment of ADHD to children aged 6 to 12. The new guidelines expand that age range to include preschoolers and teenagers.

The new guidelines were released at the annual meeting of the American Academy of Pediatrics in Boston. They are also published in the November issue of Pediatrics.

Currently, it's estimated that about 8% of children have ADHD.

The new recommendations say treatment for preschoolers should start with behavioral therapies geared toward teaching parents how to better control problem behaviors.

If a child doesn't improve, then the guidelines recommend escalating to medication with methylphenidate (Concerta, Metadate, Methylin, Ritalin).

"We're not recommending that you just put 4-year-olds on meds right away," says Karen Pierce, MD, a child psychiatrist who helped develop the guidelines. Pierce is also a clinical associate professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago.

"The kids that I put on meds, the preschoolers, have been kicked out of three or four preschools. They've had broken legs or broken arms. I have a 4-year-old who just choked his 2-year-old brother so severely because he was impulsive. Those are the kinds of kids we're talking about," Pierce says.

Evidence for Medicating Preschoolers

The committee's recommendation to use Ritalin to treat young children is in part based on the results of a study of 165 young children who were assigned to take Ritalin or a placebo. In that study, about 21% of kids on the best dose of the medication, and 13% of the kids taking the placebo, achieved remission of their ADHD symptoms.

Researchers said that overall, they found "strong positive effects" in about half the preschoolers who took Ritalin. Those improvements were generally not as large as the benefits seen in older kids who take that drug.

Mark L. Wolraich, MD, chairman of the committee that developed the guidelines, says he doesn't think the new guidelines will encourage more prescribing of medications. Instead, he says, the update and evidence-based recommendations are important because so many primary care doctors are already treating ADHD without much guidance about what works.

Wolraich is a professor of pediatrics and director of the child study center at the University of Oklahoma College of Medicine, in Oklahoma City. "It's clear from the studies that looked at medication use that there are a number of children that are being treated," Wolraich says. "We wanted to make sure that primary care physicians, if they were going to be evaluating children, were using the best evidence for both evaluation and recommendations for treatment."