It's already the most common psychological disorder affecting American children. And updated guidelines to be released today by the American Academy of Pediatrics recommend expanding diagnosis and treatment for attention deficit hyperactivity disorder to children as young as 4.
Even for preschoolers, the new guidelines state that medication can be considered under certain circumstances.
"It's good we're addressing the fact that yes, 4- to 6-year-olds can have ADHD," said Diego Chaves-Gnecco, a pediatrician at Children's Hospital of Pittsburgh of UPMC, who believes that medication is sometimes appropriate for young children. "I have seen those cases where you work so hard and it's really hard on the families and everybody's doing their best and it's out of hand. You reach the point where medication is the last resort."
Guidelines for ADHD were last released in 2000 and 2001 and covered children between only the ages of 6 and 12.
The new guidelines recommend that 4- and 5-year-olds be treated first with behavioral therapy. For patients with a moderate to severe diagnosis who have tried behavioral interventions without significant improvement, the guidelines allow for the use of the stimulant methylphenidate, also known as Ritalin.
The committee considered the drawbacks of medicating children so young -- namely that side effects and long-term effects of medicating a child whose brain is still rapidly developing have not been thoroughly studied -- but decided that in some cases the benefits outweigh the risk. There also are the known long-term effects: At least one study tied stimulant medications in children to diminished growth in the range of 1 to 2 centimeters.
"One of the requirements in the diagnosis is that it's causing significant impairment -- a child kicked out of two or three preschools," said Mark Wolraich, a professor of pediatrics at the University of Oklahoma Health Sciences Center and chairman of the committee that developed the recommendations. "It's a serious problem. When you let it go untreated, you're not necessarily doing the child a favor."
Medicating children at any age is a hard decision for parents, said Beth Tauberg, coordinator of the Pittsburgh and vicinity chapter of Parent CHADD, a support group for families dealing with childhood ADHD.
"Nobody wants to give their kids drugs," said Ms. Tauberg, of O'Hara, whose now 20-year-old son was diagnosed with ADHD at age 6. "I would guess for parents of younger kids, that decision would be even more difficult."
The new guidelines also include treatment guidelines for teenagers and options for children who fall short of an ADHD diagnosis but still have attention or hyperactivity problems. The report also emphasizes that ADHD is a chronic condition and shouldn't be managed as if it will be cured or that children will grow out of it. It also stresses the recommendation, also in the previous guidelines, that pediatricians follow the strict diagnostic criteria delineated in the Diagnostic and Statistical Manual of Mental Disorders.
Though some of the new guidelines essentially catch up to what pediatricians have already been doing, others could change current practices. Currently, most primary care pediatricians don't medicate children younger than 5 or 6, said Gary Swanson, a child psychiatrist at Allegheny General Hospital.
Dr. Swanson said he supports using medication on preschoolers in some circumstances. "If you see ADHD as a neurodevelopmental problem, it will be an ongoing, chronic kind of problem," he said. "Using whatever works as quickly as possible makes sense rather than waiting for a kid to grow out of it and watching them struggle for a couple of years."
The reason why age 6 was previously used as a lower limit for ADHD diagnoses is because that's when children historically started school. Teachers might notice symptoms at that time, or a child might struggle to behave as their peers are able to.
As more children are attending preschool, those symptoms start to show up earlier, Dr. Swanson said.
Dr. Wolraich argues that early intervention is just as appropriate for ADHD as for neurodevelopmental disorders such as autism and cerebral palsy. Left untreated, ADHD can show itself in much more serious problems in adolescence and adulthood, he said, such as substance abuse, motor vehicle accidents and incarceration.
Despite concerns raised in recent years about the over-medication and over-diagnosis of ADHD, particularly in boys, Dr. Wolraich believes the disorder is still under-diagnosed. Prevalence studies estimate that 8 percent of children are affected by ADHD.
Anya Sostek: firstname.lastname@example.org or 412-263-1308.