In late October 2011, the American Academy of Pediatrics (AAP) released new guidelines for the diagnosis and treatment of ADHD, updating guidelines that dated back to 2000 and 2001. The biggest change is that the guidelines were expanded to include recommendations for children and adolescents ages 4 to 18. The previous guidelines included children ages 6 to 12.
There are two recommended forms of treatment for ADHD, medication and behavior therapy. The new guidelines recommend starting with a course of behavior therapy in preschool age children (ages 4-5) and adding medication if necessary. For older children, they recommend a combination of medication and behavior therapy.
AboutOurKids: What would you say to a parent who sees the new AAP guidelines and says, now they're saying doctors can prescribe ADHD medication to preschoolers and teens: This is just another example of how we are over-medicating children.
Dr. Tim Verduin: There are valid reasons people feel that ADHD medications are over-prescribed, because a good number of children who are diagnosed and treated for ADHD did not go through the most rigorous evaluations. An ADHD evaluation should take hours and involve pretty much everyone who has a good deal to do with this child: parents, teachers, coaches; the child herself. It's just not possible in a 15 or 30 minute evaluation in a doctor's office. And we should be concerned about what meds we're giving our kids, because we don't always know the potential outcomes.
But there are a few things that are different about ADHD. This is a condition that has been identified in children and researched, in different forms, for almost 100 years. The medicines we use to treat it were the first ones to be researched for treating childhood emotional and behavioral issues, starting in the middle of the 20th century. There is a lot of longitudinal research, some of it right here at NYU, that looks at long-term risks, and so far not a lot have been uncovered.
I would also tell parents to read the guidelines. Even though they're intended for clinicians, having read them from the vantage point of an in-the-trenches clinician, I can tell you that they are very well written. They consider the best research out there. And they're very conservative. They're very careful to make recommendations based on science, not based on general practice or what drug companies are suggesting.
Parents trying to decide whether to medicate their child should read as much good, scientifically based literature as they can. They should ask questions of people they trust, and try to find someone with a good skeptical eye about how to handle this problem in kids.
If everybody treating ADHD read the new guidelines, we'd have much better care; a much better job of evaluating kids, and a much better job of treating them. A lot of the people who have gripes about ADHD are talking about ADHD when it is diagnosed and treated completely differently that what these guidelines recommend—when it is evaluated very perfunctorily, and when it's treated without much attention to detail. I have a problem with that too. I don't blame people for being skeptical in those instances. As you can see, good clinicians are passionate about this issue.
AOK: What led the American Academy of Pediatrics to change the guidelines?
Dr. Verduin: Findings from recent major studies show that preschool-age children, like school children, can be diagnosed in reliable and valid ways with ADHD, and that they respond to the same forms of treatment. Preschool kids often present with the same symptoms, or even more severe, than their older counterparts. So the AAP expanded the recommended age range at which kids can be diagnosed and treated, and the guidelines summarize the evidence that treatment can be as effective in preschoolers as in older children. The guidelines also clarify some of the different considerations for clinicians in treating preschool ADHD.
AOK: Preschool kids generally aren't required to sit still or be attentive for very long. How do parents and clinicians know a preschooler's behavior falls in disorder range?
Dr. Verduin: ADHD diagnoses are based on a number of criteria, and one of them is the symptom criteria: You have to have a certain number of ADHD symptoms, and by have, that means at a frequency greater than one would expect given your age. By greater, that means in the 90 to 95th percentile in terms of hyperactivity, impulsivity, and inattention, relative to your peers.
Since the base rate of these behaviors is much higher in average preschoolers than in older kids with ADHD, by extension, if a preschool child falls in the 95th percentile, they're extremely hyperactive, inattentive, and impulsive. Usually it's the hyperactivity and impulsivity that show up rather than the inattention.
So what do we mean by very hyperactive? We mean kids who are rocketing around the room, who won't stay still for a very short period of time, like a bus ride, or sitting at the dinner table; levels of hyperactivity so profound that at times it's almost impossible to help control them. We're also talking about levels of hyperactivity and impulsivity that can be dangerous.
Impulsivity means acting without thinking, and that's generally what preschoolers do. What we're looking for is more instances and more severity: aggressive behaviors—biting, hitting, kicking, pulling hair—at ages 4 and 5, when most children do those things at ages 2 and 3, if at all; running out into the street; doing very physically daring things on the playground that can, and often do, lead to emergency room visits. These are the sorts of very concerning impulsive and hyperactive behaviors that are 95th percentile-level stuff for kids who are 4 and 5.
If we're not seeing those sorts of behaviors consistently, it's unlikely a child is in disorder range. Inattention is tougher to gauge, because the demands placed on preschoolers are relatively low, and most kids are able to meet those demands. Generally what this looks like is a complete failure to attend to instructions. Often a parent will say that they can tell their child simply isn't hearing them, and it's when they're giving simple instructions or asking something the child would want to respond to, like do they want some ice cream. The kid is hyper focused on something, or distracted, and simply doesn't hear them.
AOK: Once a diagnosis is made in a preschooler, how does treatment differ?
Dr. Verduin: Preschoolers do respond to medication, which is generally the first line of treatment for ADHD in school-age kids. But especially in the early part of treatment, medications can have more pronounced side effects in younger children. We don't know as much about the effects of these medications on growth in preschoolers. So generally clinicians should be more cautious in recommending medication for these kids. It's one of the reasons the American Academy of Pediatrics recommends trying behavior therapy first in this age group.
In older kids who have severe ADHD, and in younger kids with dangerous behaviors, the guidelines do suggest trying medication sooner, possibly in concert with behavior therapy, as the "best practice."
AOK: What are some of the most common and effective forms of behavior therapy for preschoolers with ADHD?
Dr. Verduin: As it happens, the most common is not the most effective. The most widely available psychotherapy approach for preschool age kids is play therapy: individual psychotherapy with a kid where there is play going on. There may be some adjunctive sessions where the parents are given general parenting advice. But there isn't any evidence this form of therapy is helpful for kids with ADHD, or even for more general behaviorial issues for that matter.
The most effective behavioral therapies involve changes in the parent-child or teacher-child relationship, by teaching adults how to interact differently with kids. The most well-researched of these is a set of interventions called parent training. It goes by parent management training, or behavioral parent training.
These are based on something called social learning theory. The basic idea is that you use parent attention to shape child behavior, through something called selective attention. Selective attention essentially means giving a lot of positive attention to behaviors you want to see more of—in an ADHD kid, this might be sitting in his seat, asking permission before doing something, following directions the first time—so you'd give positive attention to those. In contrast, when a child uses a behavior to get out of something, or to get something, parents remove attention (as opposed to giving negative attention) for most of those behaviors, unless it's dangerous to remove attention. That's the first stage.
The second stage is teaching adults how to give effective instructions and set clear limits and expectations, and how to follow up with consistent consequences, positive and negative.
That is the foundation for almost all good evidence-based behavioral interventions for these kids. It always includes direct involvement of parents, and/or teachers, so there isn't a lot of individual therapy going on there. As kids get older, you start to involve them in setting the rules and the consequences. But preschoolers are almost completely uninvolved in that process.
The treatment, when done best, usually involves live skills coaching—meaning we don't just teach adults the skills, we coach them live while they're learning and practicing. We do a form of this here at the CSC called Parent-Child Interaction Training, or PCIT.
AOK: How widely available are good behavior therapy programs?
Dr. Verduin: The access is improving. In larger cities, around university medical centers and in college towns, you can find more good behavior therapy than you could 10 years ago. But the American Academy of Pediatrics allows for that real consideration by saying you may opt to go to medication sooner, if you don't have access to good behavior therapy. That's actually in the guidelines.
AOK: Why isn't behavior therapy the "first line" treatment for all ages?
Dr. Verduin: There is more evidence that behavior therapy is effective in young kids. It makes sense. The vector for change in behavior therapy is the way parents and teachers interact with children, and young kids are generally more receptive to changes in discipline than older kids. The older a kid gets, the harder it is to make changes in terms of behavior therapy.
So not only are the risks of medication potentially higher for younger kids, but the benefit of doing behavior therapy first appears to be greater.
As a potential added benefit, not only are children's relationships with parents still forming and very influential at this age, there is a lot of neural development happening. There is hope that if we get in there early and create behavior changes, it may lead to neurological-development changes as well.
AOK: The APP and the American Academy of Child and Adolescent Psychiatry both recommend combined treatment—medication and behavior therapy—for the majority of ADHD cases. What does medication do that behavior therapy can't?
Dr. Verduin: What do not seem to respond to behavior therapy are the so-called core symptoms of ADHD. Very few people who know the literature would say that you can cure ADHD or even make a substantial impact on inattention, hyperactivity and impulsivity with behavior therapy, because there have been many failed trials of programs meant to make those changes.
What we have found, though, is that a lot of the things that are impairing for kids with ADHD, like noncompliance, organizational skills problems, and relationship problems with their families, do respond well to behavior therapy. In fact we've developed an Organizational Skills Training intervention here at the CSC that has been proven to really help school age children with ADHD in this arena, and there is some initial evidence that it may help middle school children as well.
When parents come to us, they're not generally saying, can you reduce my child's ADHD symptoms. They're looking for help at the dinner table, on play dates, at homework time. Behavior therapy helps with these issues.
So with behavior therapy alone, what you have is an ADHD kid, who's still got ADHD, but who is much easier to manage, has a better relationship with their parents, has more organizational skills, and has better structure in their life. So that is a message of hope for people. But it's important not to say, well, in preschoolers, you're going to get rid of the ADHD with behavior therapy.
AOK: Since in most cases both medication and behavior therapy together are the recommended treatment, how do clinicians decide which to start when?
Dr. Verduin: It's a case by case decision. We generally would recommend starting first with a lower risk treatment that has a good chance of success, in any branch of our discipline.
We look at several things, starting with the severity of the problem, and whether there are any imminent potential consequences to not acting fast. Is the kid on the verge of failing out of school? Are they having dramatic changes in their self-concept, or their attitude toward school or their teachers? If so, we might move toward medication more quickly. Then, how receptive is the school to any strategies we might want to try with the child, how much support can they give? Are the parents comfortable with us working directly with the school, because some parents are concerned their child might be stigmatized.
Are there are other problems in the mix as well—an autism spectrum disorder, anxiety, depression—that would need more assessment before beginning behavior therapy? Another thing we look for is prior history with behavior therapy. If this is a child who has tried behavior therapy without improvement, we're likely to move to medication faster. Lastly, how motivated is the child to work on the problem, because behavior therapy takes a lot of work—everybody's got to work really hard.
In younger kids, again, parents want us to be more involved, teachers want to do more, there are fewer complicating factors with behavior therapy. The severity issue is still there, and we will still act faster with meds if we have a severely impaired kid, who is on the verge of getting kicked out of school, for instance, or possibly for preschoolers engaging in a lot of the dangerous behaviors mentioned earlier.
AOK: Why did the AAP make changes to their recommendations regarding adolescents?
Dr. Verduin: When the original recommendations for best practices were made, there were fewer data about how teenagers respond to ADHD medication. One of the reasons is simply that teenagers with ADHD are harder to assess. They're likely to have the most impairment at school, due to inattention. But because middle schoolers and high schoolers have multiple teachers, it can be hard to get a very clear picture of what is going on in terms of ADHD with kids this age. (Adolescents tend to have fewer problems with hyperactivity and impulsivity, since as the brain matures those issues tend to wane, treated or not.)
We now have better methods for assessing ADHD in teens, in addition to more data on how adolescents are responding to ADHD medication and other forms of treatment. Researchers have been following some of the kids who were in earlier ADHD studies as they grow up. We're finding that they continue to respond well to medication as they get older.
Another reason the guidelines were updated is that historically there have been some concerns that teenagers with substance use issues, or teenagers with friends with substance use issues, add a potential risk to giving them medications that could be abused. The new guidelines recommend stimulant medications that have a lower risk of abuse. They also caution physicians to look carefully at potential misuse or diversion of substances—teens giving them or selling them to friends.
AOK: Does expanding the guidelines to include diagnosis and treatment of teens have any relation to the diagnosis of ADHD being opened up to adults?
Dr. Verduin: Actually one of the fastest growing areas in ADHD research and treatment is adult ADHD. It's all through the language of the APP's best practices guidelines that this is a chronic condition. Physicians and treating clinicians need to have treatment options for people throughout the lifespan.
Orignially published Nov. 2011