Attention Deficit Hyperactivity Disorder in Preschool Children

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Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with a childhood onset of symptoms and impairment. Although it is most frequently identified during elementary school years, epidemiologic data suggest that the onset of ADHD frequently occurs earlier, with presentation as young as 3 years of age. Early identification, however, allows consideration of appropriate interventions. Many data are available on safe and efficacious treatment options for school-aged children who have ADHD; however, little is known about the use of these modalities in preschoolers and, ultimately, the long-term effects of early treatment. Recognition of the preschool presentation of ADHD, appropriate differential diagnosis, and identification of comorbid conditions, and a developmental perspective on the course and potential outcomes of the disorder may guide treatment planning. Newly available data on the safety and efficacy of pharmacotherapy and psychosocial intervention for preschoolers who have ADHD may help clinicians make treatment decisions for these young children and their families.

Section snippets

Prevalence of preschool-onset attention deficit hyperactivity disorder

Early onset of ADHD symptoms and associated impairment has been reported in community and clinical samples [9], [10]. Although initial ADHD symptoms may be noticed as early as 3 years of age [11], [12], the most common age of full ADHD diagnosis does not occur until 7 to 10 years of age [13]. Epidemiologic surveys of community samples have reported that 2% to 6% of preschoolers met full criteria for ADHD [12], [14], [15], somewhat lower than the worldwide 5.7% prevalence rates reported for ADHD

Diagnostic validity

The validity of an ADHD diagnosis in the preschool years has often been questioned. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) does not provide specific, developmentally adjusted ADHD criteria that apply to preschoolers. Rather, the same diagnostic criteria are applied to patients across the lifespan. The frequent use of pharmacotherapy in treating preschoolers, however, makes determining a valid diagnosis at this young age important [21]. Consequently,

Impairment with attention deficit hyperactivity disorder

Current DSM-IV diagnostic criteria for ADHD require demonstration of impairment in a minimum of two settings [25]. Symptoms of ADHD in preschoolers produce significant impairment in a multitude of settings, including home, school, and during social functioning, even to the degree of impacting the child's safety [6], [20], [26]. Compared with same-aged controls, preschoolers who have ADHD are more often suspended from preschool or daycare (15% versus 0.8%) because of disruptive behavior (7.8%

Comorbidities

Just as with older children, preschool ADHD frequently co-occurs with other psychiatric disorders [31]. Young children who have ADHD have been shown to have increased rates of developmental delays and developmental coordination disorder [32]. Of preschoolers who had ADHD, 22% also had a language disorder [33]. High rates of language problems have also been reported in other preschool ADHD samples [7], along with underachievement in reading and math [6]. Like their school-aged counterparts,

Persistence of attention deficit hyperactivity disorder symptoms with preschool presentation

Longitudinal studies report that preschool-onset ADHD symptoms may persist over time [6], [21], [40]. ADHD symptoms identified in 3-year-olds remained in 50% of those children by 6 years of age, and 48% by 9 years of age [11], and the same children were more likely to meet diagnostic criteria at 13 years of age than comparisons [40].

Nearly all of the 255 4- to 6-year-olds who had ADHD followed up for 3 years by Lahey and colleagues [21] continued to meet criteria for one subtype of ADHD,

Use of methylphenidate in children younger than 6 years who have attention deficit hyperactivity disorder

Despite a U.S. Food and Drug Administration (FDA) warning against its use in children younger than 6 years, methylphenidate has frequently been prescribed off-label for treating ADHD symptoms in preschoolers. As early as 1990, 34% of pediatricians and 15% of family practitioners reported prescribing stimulant medications to preschoolers who had ADHD [42]. This off-label use of methylphenidate increased between 1990 and 1995 [43], with a 49% increase between 2000 and 2003 for ADHD in children

Summary

Preschool ADHD is an impairing behavioral disorder, and it co-occurs with other serious psychiatric disorders. Early identification of ADHD and intervention may potentially minimize or prevent adverse outcomes and future pathology. Although data from studies of school-aged children have guided the use of stimulants in preschoolers, the limited safety and efficacy information on the short- and long-term effects of these medications in young children makes initiating pharmacotherapy a difficult

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    • Cited by (0)

    Dr. Greenhill has received support from Celltech, Cephalon, Eli Lilly, Janssen, McNeil, Medeva, Novartis Corporation, Noven, Otsuka, Pfizer, Sanofi, Shire, Solvay, Somerset, and Thompson Advanced Therapeutics Communications. As part of an effort to help execute the FDA suicidality classification mandates, Dr. Posner has received funding from the FDA to develop and implement the suicidality classification system used in their child antidepressant safety analyses. This system was subsequently used in the adult antidepressant safety analyses. As part of an effort to help execute the FDA suicidality classification mandates, Dr. Posner has had research support from Abbott, Bristol Myers Squibb, Organon, Schwarz, GlaxoSmithKline, Eli Lilly, Johnson and Johnson, Wyeth Research, Sanofi-Aventis, Cephalon, Novartis, Shire Pharmaceuticals, Merck, Pfizer and Vivus. Dr. Kratochvil has received support from Cephalon, Eli Lilly, McNeil, Abbott, Pfizer, Shire, Somerset, and AstraZeneca.

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