Over the weekend, the American Academy of Pediatrics updated its guidelines for diagnosing and treating attention deficit hyperactivity disorder in youngsters and children, and one recommendation is likely to cause some debate. The AAP now suggests that primary care doctors consider prescribing ADHD meds to kids as young as four years old with "moderate to severe dysfunction" if behavior therapy does not work.
“Treating children at a young age is important, because when we can identify them earlier and provide appropriate treatment, we can increase their chances of succeeding in school,” says Mark Wolraich, the lead author, a professor of pediatrics at the University of Oklahoma College of Medicine and a consultant to a few drugmakers, says in a statement. “Because of greater awareness about ADHD and better ways of diagnosing and treating this disorder, more children are being helped.”
The recommendation of an AAP steering committee is part of an effort to update guidelines last issued a decade ago and, simultaneously, expand the age range that was covered previously. Now, the AAP says "emerging evidence" makes it possible to diagnose and manage ADHD in children from ages four to 18 years old, while the last set of guidelines covered children ages six to 12 years old.
The APP recommendation is likely to cause a stir, given what is already a long-standing debate about what some say is an overreliance by school districts on ADHD meds to cope with children who have behavioral issues; concerns about misdiagnosis, and uncertainty about effects on children who take the pills for an extended period. Other issues include effect on growth and suicidal thoughts.
For instance, Strattera, which is a selective norepinephrine reuptake inhibitor, carries a Black Box warning that "some children and teenagers may have a higher chance of having suicidal thoughts or actions. Although no suicides occurred in these studies, four out of every 1,000 patients developed suicidal thoughts." The drug, which is sold by Eli Lilly, is approved for children who are six years old and up.
Anticipating a backlash, the AAP paper acknowledges that "children in whom ADHD is inappropriately diagnosed might be labeled inappropriately, or another condition might be missed, and they might receive treatments that will not benefit them." And preschoolers are unlikely to have a "separate observer if they do not attend a preschool or child care program, and even if they do attend, staff in those programs might be less qualified than certified teachers to provide accurate observations."
The AAP also acknowledges another limitation. Although the AAP provides guidelines for diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders for Primary care, the AAP notes that behavioral descriptions have "not yet been tested in community studies to determine the prevalence or severity of developmental variations and problems in the areas of inattention, hyperactivity, or impulsivity" (you can read the AAP committee paper here).
As for side effects the meds may cause, the AAP paper acknowledges that preschoolers might experience "increased mood lability and dysphoria," which can generally refer to discontent or a form of depression. And mood lability is another way of saying mood changes. The paper notes that only dextroamphetamine - also known as Dexedrine among other names - is approved by the FDA for use in preschoolers.
And the AAP concedes that only one multi-site study has carefully assessed medication use in preschoolers. This involved methylphenidate, also known as Concerta and Ritalin. And there is limited experience and information about the effects. While there were also 10 single-site studies, most of which the paper reports demonstrated significant efficacy as well as moderate safety evidence, use in preschoolers remains off label.
Despite the qualifiers, the AAP maintains there are strong reasons for docs to consider prescribing the meds. For one thing, the AAP cites reports suggesting 8 percent of kids have ADHD. Moreover, the committee argues that the actual number of children with ADHD is far greater than can be managed by the mental health system. "Treatments available have shown good evidence of efficacy, and lack of treatment results in a risk for impaired outcomes," according to the AAP steering committee paper.
Certainly, there are preschoolers whose attention can be improved, although there are also developmental differences to consider when considering their situation with other children. And the AAP does acknowledge some qualifiers before plunging ahead with prescriptions. What do you think?
Should ADHD Meds Be Prescribed To Preschoolers?
- No (96%, 158 Votes)
- Yes (4%, 7 Votes)
Total Voters: 165