ADHD Guidelines Issued for 4 and Up

Attention deficit hyperactivity disorder can be diagnosed in children as young as age 4, according to new treatment guidelines by the American Academy of Pediatrics.

The guidelines, released Sunday at the academy's annual meeting in Boston, provide instructions for pediatricians on diagnosing and managing ADHD in children 4 to 18. They say behavioral management techniques should be the first treatment approach for preschool-age children.

But they also suggest doctors consider prescribing methylphenidate, commonly known by the brand name Ritalin, in preschool-age children with moderate to severe symptoms when behavior interventions don't provide significant improvement.

It's a potentially controversial recommendation, because these medicines aren't approved by the Food and Drug Administration for use within that age group.

Many ADHD medications are approved for use by people 6 and older. The prior set of ADHD treatment guidelines from the academy, issued about a decade ago, gave recommendations for children 6 to 12. Along with preschool-age children, the new recommendations also address teenagers who might not have been diagnosed at a younger age.

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Once drugs are approved, the FDA doesn't regulate how doctors prescribe the medications, allowing them to prescribe them for uses beyond the FDA-approved label.

ADHD is the most common neurobehavioral disorder in children, occurring in about 8 percent of children, according to the academy. The condition is often marked by the inability to focus or pay attention, hyperactivity and impulsive behavior. The behavior problems are so frequent that they interfere with the child's ability to adequately function on a daily basis without treatment.

Mark Wolraich, the lead author of the ADHD clinical practice guidelines and a professor of pediatrics at the University of Oklahoma Health Sciences Center, said ADHD in a preschool-age child was very different from the typically active behavior seen in most young children. A child with ADHD often doesn't play well with other children, is prone to accidents and is overactive much of the time.

"It's not the environmental things like parties triggering it," Dr. Wolraich said.

To properly diagnose a child with ADHD, the guidelines said, the overactive, impulsive behavior needs to be seen consistently for four to six months in both the home and another environment, like school.

The guidelines suggest parents undergo training to help modify behaviors associated with ADHD. Such techniques involve setting up a reward-and-punishment system and stress the consistent application of the modification techniques.

Medication should be considered for preschool-age children only if they exhibit symptoms of ADHD for at least nine months and only after behavior management techniques have been tried, according to the guidelines.

Andrew Adesman, the chief of developmental and behavioral pediatrics at the Steven & Alexandra Cohen Children's Medical Center of New York, said he thought the guidelines were "well thought out and helpful to pediatricians," who often have to deal with diagnosing and treating ADHD.

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