In October 2012 the American Academy of Pediatrics* issued new guidelines for the diagnosis and treatment of ADHD. While most of the guidelines are relatively straight forward the one area of controversy is the recommendation that children as young as age 4 can be diagnosed and treated for ADHD (lowering the threshold age for diagnosis from 6 to 4). The Academy appears to be trying to balance early intervention with caution as Academy guidelines include a number of criteria that physicians should heed before diagnosing a younger child:
• All of the DSM IV criteria should be clearly met including the presence of significant impairment in more than one setting.
• Information should be obtained from more than just parents, i.e., teachers and other professionals.
• Alternative or co-existing conditions or problems should be considered and ruled out: learning problems and other developmental disorders; emotional and behavioral problems including anxiety and depression; and physical illnesses, e.g., sleep apnea.
However, even with these cautions the lowering of the age threshold is cause for concern. First, significant changes can occur in younger children in 6-12 month periods. What might appear to be overactive behavior, poor attention, or impulsivity may be well within the normal range of development, for a 4 year old. Second, the impact of family environment (stress, conflict, etc) is not fully considered. Family disruption can significantly affect children and younger children are particularly prone to acting out emotional distress. Moreover, assessing family functioning is often not in the purview of most physicians. Third, the assumption inherent in the guidelines is that physicians will adhere to DSM IV criteria, and carefully assess for ADHD symptoms while also carefully ruling out alternative diagnoses. Given the time pressures on physicians this assumption may not be always warranted.
Therefore, it would seem more prudent for professionals working with younger children who exhibit ADHD like symptoms to follow the Academy’s recommendation that behavioral therapy is the first line intervention in treating younger children with ADHD like symptoms. Moreover, an even more conservative approach would be to defer diagnosis and utilize behaviorally focused family behavioral treatment to address the specific concerns that parents have raised about their child’s behavior. This approach not only allows for treatment of parental concerns, but also provides a forum where more thorough assessment (particularly of familial issues, but also of other concerns) can take place. Finally, a recent summary** of treatment for preschoolers with ADHD like symptoms concludes that parent training programs, ones that emphasize the use of positive reinforcement and the strengthening parent-child relationship, are the most appropriate treatment intervention. Thus, it would seem that the most appropriate intervention for younger children (those under age 6) who present with ADHD like symptoms would be a behavioral focused treatment which also includes assessment of other concerns (family stresses, developmental problems, health problems).
In conclusion, early diagnosis is not wrongheaded. Clearly, if the generally accepted assumption that ADHD is a genetic disorder is correct, there are younger children with ADHD. The problem is that diagnostic methods are not sufficiently precise to differentiate ADHD from normal developmental challenges, in younger children. Therefore, a more conservative approach appears warranted.
*http://pediatrics.aappublications.org/content/early/2011/10/14/peds.2011-2654
**http://www.effectivehealthcare.ahrq.gov/ehc/products/191/818/CER44-ADHD_20111021.pdf (Attention Deficit Hyperactivity Disorder: Effectiveness of Treatment in At-Risk Preschoolers; Long-Term Effectiveness in All Ages; and Variability in Prevalence, Diagnosis, and Treatment. Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services, 540 Gaither Road, Rockville, MD 20850. www.ahrq.gov).