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HYPERACTIVITY DISORDER IN PRESCHOOLERS
ATTENTION-DEFICIT/HYPERACTIVITYDISORDER
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ATTENTION-DEFICIT / HYPERACTIVITY DISORDER IN PRESCHOOLERS Does It Exist and Should We Treat It? James A. Blackman, MD, MPH
Marvin, 4 years old, has just been expelled from preschool for aggressive behavior. Carolyn, 2.5 years old, is so motorically wound up that she takes no naps, finally falls asleep at 11:OO PM, and awakens at 6:OO AM. Leah, 3 years old, cannot be trusted to play unsupervised. She has been to the emergency department three times for toxic ingestions and pushed the new puppy off the bed, dislocating its hind limb. Two weeks after his second birthday, Kelly’s longedfor toys are already broken. Rarely did his interest in any one of them last for more than a few minutes. The parents of these young children are exasperated, tired, embarrassed, and sometimes fearful. At these ages they are most likely to turn to their child’s primary care physician for help. Some parents already have a specific agenda: they want medication to control the hyperactivity and impulsiveness, regardless of the child’s age. Others are more open, perhaps naive initially, and seek a better understanding of their child’s behavior as well as various options for management. Each of these children might warrant a diagnosis of attention-deficit/hyperactivity ’disorder (ADHD). However, their behaviors are also consistent with a variety of other diagnoses, including normal behavior for age or developmental level. Distinguishing between the possibilities and making the medically and ethically correct decisions are exceedingly challenging in early childhood. The purpose of this article is to review the literature regarding the diagnosis and management of ADHD in preschool-aged children and to offer specific
From the Division of Developmental Pediatrics, University of Virginia; and Kluge Children’s Rehabilitation Center, University of Virginia, Charlottesville, Virginia
PEDIATRIC CLINICS OF NORTH AMERICA ~
VOLUME 46 * NUMBER 5 * OCTOBER 1999
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strategies for approaching this formidable challenge in pediatric practice based on this review, personal experience, and the experience of colleagues. NATURE OF THE PROBLEM The essential features of ADHD-inattention, impulsivity, and hyperactivity-are apt descriptors of the behavior of most preschool-aged children at one time or another. Activity and attention vary with age and developmental level. The DSM-IV2 states that toddlers and preschoolers with ADHD "differ from normally active young children by being constantly on the go and into everything. They dart back and forth, are out the door before their coat is on, jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in preschool classes (e.g., listening to a story)." A child with ADHD has difficulty playing alone for more than a short time, destroys rather than plays with toys, and may have few friends because of aggression and inability to cooperate in play. High activity rather than inattention is likely to be the symptom most noticeable in preschool-aged children. However, inattention and impulsivity are evident in the child's carelessness, failure to complete tasks, and difficulties following instructions. Even the attention of toddlers can be held in a variety of situations (e.g., the average 2- to 3-year-old child typically can sit with an adult to look through picture books). In contrast, young children with ADHD move excessively and typically are difficult to contain.z Certainty in the diagnosis of ADHD in preschoolers is difficult because of the day-to-day variability of behavior, situational responses to the environment, and adult interpretations of behavior. Children may be revved one day, placid the next. At indulgent Grandma's or at a sensory-overloading supermarket they may be uncontrollable, whereas at a structured day care setting they are compliant. Mom, who is exhausted from her son Charlie's insatiable demands, sees him as "hyper," Dad's interpretation of Charlie's behavior, when he is home on weekends from his long-haul trucking runs, is that he's "all boy," just like he was when he was a kid. Additional common manifestations of ADHD-aggression, noncompliance, and social ineffectiveness-may be confused with other diagnoses such as oppositional defiant disorder or difficult temperament. Of 105 children studied for disruptive behavior disorders by Reeves et a1,= fewer than half received only one diagnosis. Conduct and oppositional defiant disorders resembled each other and seldom occurred in the absence of ADHD. It is difficult to differentiate ADHD in toddlers from other discipline problems at this age. Some children simply have never learned limits, rules of behavior, or empathy. If ADHD is truly biologically based, it should be manifested from birth. For most young children, however, suspicions about ADHD do not arise until they are 2 or 3 years old. In a prospective longitudinal study by Palfrey et al,33 no infants less than 14 months of age were found to have definite concerns about attention or hyperactivity on a behavior impressions summary, and only 3% had possible concerns expressed by parents. Between the ages of 14 and 29 months of age, 13% of the study group met criteria for definite or possible concerns. The researchers suggested that this dramatic increase occurred because infants may not be confronted with the kinds of experiences and tasks that dramatize and bring forth these symptoms. As young children enter a structured preschool experience, it may be the first time in their lives when they are expected to fit into externally imposed structures, behave in socially acceptable ways, relate to peers socially, and conform to the authority of adults other than parents.
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Why does it matter whether ADHD is diagnosed before school age? Perhaps the chief pressure for making an early diagnosis is to obtain supportive services. It is unfortunate but realistic that a medical sounding label such as ADHD often qualifies for insurance reimbursement, at least for initial evaluation and sometimes short-term behavioral therapy, whereas other terms such as adjustment reaction or simply behavior problems do not. In many states, ADHD is an eligible medical diagnosis for inclusion in either early intervention or preschool special education programs under the Individuals with Disabilities Education Act (IDEA). School programs may accept ADHD as a qualifier for special educational services but not merely difficult behavior. A specific label that most parents and teachers have heard of provides a certain relief that the problem is the child’s, not the parents’, and that there is hope of a cure through medication. Most parents (backed by teachers) of problematic preschoolers leave the office happier with a firm diagnosis of ADHD than with a “Maybe,” ”We’re not sure,” “It’s too early to tell,” or “Probably not.” Determined parents may shop for a doctor until they find one who gives them the diagnosis and treatment they want. An accurate diagnosis of ADHD clearly points to the appropriate remedial action that should take place. Many preschool teachers are familiar with behavior management strategies or have access to consultants who can assist them with reward systems, classroom modifications, and time out procedures. Parents can walk into any bookstore and find useful ADHD materials for home use. Judiciously and selectively considered, medications are helpful, sometimes dramatically, in conjunction with parent counseling. Delaying the diagnosis may delay interventions that might prevent worsening of behaviors or secondary problems with self-esteem, socialization, and learning. On the other hand, there are clear dangers to early labeling, the most important of which is inappropriate labeling. In the next section, a review of longitudinal follow-up studies demonstrates the difficulties in making an accurate diagnosis in the early years of life. Even if the diagnosis is dismissed at a later age, the term ADHD remains in the medical record, to be distributed to and reviewed by numerous individuals and agencies. Any label, particularly one as loaded as ADHD, is hard to lose once attained. When the word is out that Torrance has ADHD, Torrance is the last to be chosen for the little league team, is unwelcome at other kids’ homes, and is the first one to be implicated in a disturbance in the classroom. Underachievement may be accepted as part of the syndrome. Unfortunately, the reputation usually persists, even if the diagnosis is removed. The most controversial aspect of early diagnosis of ADHD is the issue of medication. It is well accepted that stimulants and other medications are an effective and integral part of treatment for ADHD, especially when used with behavior management training. Parents and teachers beg for, demand, and expect medication for an ADHD diagnosis. Resistance to prescribing medication on the part of the physician, even with young children in whom the safety of stimulants is uncertain, is interpreted as insensitive and obstructionistic. To many, it appears illogical for a physician to make a diagnosis of ADHD then refuse to prescribe a medication to treat it. NATURAL HISTORY OF ADHD PROBLEMS
The key to deciding whether ADHD can be diagnosed confidently before school age lies with longitudinal studies. Although not plentiful, there exists important and fairly consistent information in the literature to guide such a consideration. Follow-up studies have helped to distinguish which children with
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which types of behaviors in which environments will have persistent problems at an age when a definite diagnosis is possible. In a short-term study at the Children’s Hospital in Boston, we found that only half of parents of preschool-aged children evaluated for behavior problems, including hyperactivity and inattention, continued to be concerned 1 to 2 years later, although in many of the cases teachers continued to be ~oncerned.~ Children with persistent problems tended to have difficult temperamental characteristics, such as high intensity of affective expression, difficulties with changes in routine, low sensory threshold, and arhythmicity of biologic functions. Lerner et alZ4followed 88 problem preschoolers for an average of 11.5 years and found that those children with high ratings of overall behavioral disturbance (based on chart review and formal interview using the diagnostic interview for children and adolescents) had at least twice the risk for the development of a future psychiatric disorder compared with less dysfunctional children. Initial behavior problems included verbal and physical aggression, hyperactivity or distractibility, and social withdrawal. Subjects in this study came from welleducated, middle-class families and had above-average IQs. As part of Harvard University’s Brookline Early Education Project, Palfrey et aP3 followed 174 children prospectively from birth to second grade for the emergence, persistence, and disappearance of behavioral difficulties, including attentional problems. Over the period from birth to kindergarten, 40% of the preschool children were found to have some attentional indicator, but many of the findings were minor or transient. Persistent attentional problems were identified in 5% of the children; 8% had significant problems that abated before kindergarten. The investigators found that concomitant social-emotional problems ( e g , difficulty relating to peers, fearfulness, acting out behaviors) and delays in motor function signaled a more malignant form of attention deficit that is likely to persist. Conversely, resilience, evident by abatement of attentional difficulties, was associated with higher maternal education level, greater family stability, fewer health problems, higher general cognitive ability, and stronger verbal ability. Similarly, Egeland et aPSfound that improved behavioral functioning between preschool and elementary school appeared to be related to low stress at home, higher quality of the home environment, and low levels of maternal depression. Beitchman et a16 reported on a diagnostic and symptom outcome study of 98 children who attended a therapeutic preschool program in Toronto. Children were admitted to this program with behavior problems severe enough to warrant a comprehensive approach to treatment that included individual psychotherapy, supplemental developmental support activities, and family counseling. The sample consisted of 84% boys, with age ranges of 2.5 to 6 years. The average interval of follow-up was 5 years after discharge from the program. Approximately half the children were from intact families, one third from single parent families. The remainder was with stepparents or in foster homes. The average IQ of the initial sample was 90 on the Stanford-Binet Intelligence Scale. Sixty-nine percent of the children seen at follow-up were found to have diagnosable DSM-I11 disorders, compared with 90% at initial assessment. Thus, although there was some improvement in the 5 years since discharge from the preschool, a substantial number of children continued to show evidence of a DSM-111 disorder. In most instances the DSM-111 disorder was the same at follow-up as it was initially. The diagnostic groups that showed the greatest stability in behavior over the 5-year period were those with developmental delay or attention deficit disorder or both. The group with conduct disorder showed only moderate stability. In contrast, the children with emotional disorders received similar diagnoses only 29% of the time, reflecting the lowest level of diagnostic continuity.
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Of 1037 children followed from age 3 to age 15 in the Dunedin Multidisciplinary Health and Development Study, 2% (13 boys and 8 girls) were identified as "pervasively hyperactive" initiallyz8 Compared with nonhyperactive preschoolers, these children more often came from families with high levels of adversity, and they showed poorer language skills. Over a 12-year follow-up period, the hyperactive preschoolers continued to show significantly poorer cognitive skills, lower levels of reading ability, disruptive and inattentive behaviors at home and at school, and higher rates of DSM-I11 disorders of preadolescence and adolescence than comparison children. By age 15, only one fourth of this group was identified as having met full recovery criteria. However, only 2 of the original group of hyperactive children received the diagnosis of attentiondeficit disorder (ADD). (Author note: ADD rather than ADHD is used in those instances in which ADD was the terminology used in the study report). The importance of this study is that it was conducted on a nonreferred population of children and thus provides a more naturalistic view of behavior problems among preschool-aged children and their outcomes. In subsequent analysis of the Dunedin data, researchers reported that the earlier the onset of ADD symptoms, the more likely behavioral and developmental morbidity would persistz9 Campbell et allz followed hard-to-manage preschool-aged children recruited at age 3 and 4 identified by parent complaints of inattention, overactivity, and discipline problems. At age 6 only 50% of the group met criteria for ADD or were perceived by parents to have significant problems. At age 9, 48% met DSM-I11 criteria for an externalizing disorder (ADD and/or oppositional defiant disorder or conduct disorder) compared with 16% of comparison children." These studies indicate that serious problems with aggression and impulse control during the preschool years, overlapping with attentional problems, often persist to school entry and beyond. Such difficulties may be exacerbated when the family environment is more chaotic and less supportive and when parents themselves do not foster their young child's self-regulation and behavioral contr01.'~However, it is important to recognize that for half of the preschoolaged children with these problems, symptoms are transient and eventually abate. Distinguishing between these groups and selecting those with ADHD is the challenge. Accumulating evidence suggests that preschool-aged children are more likely to show overactive, noncompliant, aggressive, and impulsive behavior in the context of uninvolved, rejecting, or harsh parenting. On the other hand, warmth, responsiveness, and appropriate limit setting foster the development of more socially competent behavior in young children. The absence of these qualities of parenting or overt rejection and negative control are likely to be associated with persistent problems. The onset of problems is often associated with emerging family difficulties, whereas amelioration of problems is often associated with improvement in the quality of family relationships. It appears likely that biologic tendencies in the child interact with the caregiving environment to produce either adaptive or maladaptive outcomes that may vary at different developmental transition points.'" These observations raise the possibility that early recognition of problems, regardless of what label is used, and appropriate interventions, particularly in the psychosocial sphere, have the potential of averting or at least ameliorating future problems. ORIGIN OF ADHD IN PRESCHOOL-AGEDCHILDREN
The title of this section should more properly read the etiology of ADHDlike symptoms in preschool-aged children. That true ADHD exists and can be
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detected in this age group is beyond doubt. The problem is that multiple etiologies lead to similar symptomotology (Fig. 1).Both neurologic and genetic factors have been implicated in the causation of ADHD. Acquired brain injury, prenatal exposure to toxins such as alcohol, and perinatal complications including preterm birth and birth asphyxia have been associated with ADHD. Clearly, ADHD runs in families, supporting the inheritable nature of ADHD. Genetic factors seem to account for most cases of ADHD. In some cases, a genetic predisposition toward ADHD may be exacerbated by brain injury. Although psychosocial and environmental factors are no longer believed to cause ADHD, such factors can lead to behaviors that mimic ADHD. Chaos or stability in the life of a child with ADHD either exacerbates or ameliorates the expression of symptoms. In Campbell's study of difficult-to-manage preschoolaged boys who were rated as overactive, inattentive, and impulsive by teachers, problems were most likely to persist when symptoms were severe and mothers were negative and controlling and family stress was more severe and chronic." In less stressful family settings in which mothers were more patient and less negative, boys with the same initial behavioral characteristics had fewer problems at follow-up. A group of comparison boys without problems at first but living in dysfunctional family settings developed problems at age 6. Finally, boys with low levels of initial problems living in normal family environments remained symptom free. These observations have obvious implications for intervention to be discussed later. Preschoolers who manifest aggression in addition to hyperactivity are particularly problematic. Such children have been found to have families whose fathers are highly restrictive, mothers who report both giving verbal and receiving physical aggression, and siblings who retaliate aggres~ively.~~ Persistent Psychosocial stressors Chronic disease \
I
Syndromes (e.g.:Williams)
Information
ADHD
Medication
INATTENTION IMPULSIVITY HIGH ACTIVITY LEVEL defiant disorder
Emerging conduct disorder
I
Mental retardation
caregivers Figure 1. Differential diagnosis for ADHD-like symptoms in preschool children.
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aggressive behavior was predicted by initial child unmanageability, maternal depression, perceived lack of support, and low income. ASSESSMENT APPROACH Because the diagnosis of ADHD is so difficult in preschool-aged children, the goal of assessment should be on relief of symptoms rather than on a specific diagnosis. In some instances, specific diagnoses are obvious and necessary for obtaining services or reimbursement or both. However, a diagnostic label should not imply that the problem is exclusively within the child or must inevitably lead to drug regimens. Because a physician must make judgments about prescribing medication or behavioral therapies, he or she is ethically obligated to be as certain as possible that, based on a thorough evaluation, the child is being appropriately diagnosed. Assessment should be multidimensional, considering all possible explanations for a child’s hyperactive, inattentive, impulsive, aggressive, or noncompliant behavior (Fig. 1). Such an approach must integrate physical, emotional, cognitive, and ecologic information about the Although this wide perspective may be attainable by one individual in some circumstances, more likely an interdisciplinaryevaluation will be necessary, implemented through a variety of possible models. The child’s primary care physician is the most likely individual to whom parents bring their concerns or those of their child’s preschool teacher or day care provider. At a minimum, the physician should conduct a brief interview and examination of the child to determine whether the behavior problems are transient and easily attributable to a specific causative factor or whether they are chronic and warrant a more thorough and detailed evaluation. Unless a particular case seems clear and straightforward, the physician would be well advised to consult with specialists in child psychology and early childhood education. The primary care physician might serve as the coordinator of the evaluations in the community (involving the school, community mental health agency, or private consultants) or refer a child to a developmental evaluation center for an initial assessment, thereafter assuming responsibility for ongoing treatment and follow-up. For a familiar child who has been followed in primary care since birth, symptom evolution, family history, and the environmental context may be so clear that a diagnosis of ADHD is straightforward without extensive consultation. For a new child, however, a broader assessment is essential. Health History A general medical history is obtained to identify risk factors for ADHD or other behavior problems and to rule out any health problems that might mimic ADHD or influence behavior. Biologic risk factors such as prematurity and fetal alcohol exposure are probably more useful for research than in individual cases. If a child has problems, risk factors are somewhat irrelevant. However, coupled with a family history, positive findings increase the likelihood of an endogenous component to the behavior problems. Absence epilepsy would be an unlikely and obvious cause of attentional lapses in this age group. Some anticonvulsant medications, notably phenobarbital, commonly make young children hyperactive. Allergies are significant, not
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because they have been found to cause ADHD but because chronic nasal congestion may result in restless sleep or decongestants and antihistamines may produce behavioral disturbances. Other chronic diseases and their treatments should be explored as well for their potential impact on behavior. Parents of preschool-aged hyperactive children report higher rates of physical complaints such as bad breath, skin rashes, red cheeks, stomach bloating, stuffy and runny noses, and leg cramps than parents of non-ADHD childrenz2 Sleep problems have been cited frequently as common in ADHD. However, Kaplan et alZ3did not find differences in total sleep time or sleep onset latency between preschool-aged hyperactive and nonhyperactive children, although there was an increase in the frequency of night wakenings for the hyperactive group. These night awakenings disturb parents’ sleep; thus, they may report that these children are poor sleepers.23 The ANSER System is one method designed for health care settings that uses questionnaires completed by parents and preschool personnel to gather health, developmental, and behavioral information in a systematic manner.26 Specific versions of these questionnaires are available for preschool-aged children. Psychosocial Evaluation Primary care physicians often have an advantage of knowing families well and the environment in which the child lives. However, when.such information is not known, an in-depth interview is essential to explore such issues as family stresses, marital relations, violence, housing, and financial conditions. A psychologist or social worker is likely to obtain more information and provide valuable interpretation of the material. From Campbell’s work described earlier, family stresses and problems are significant determinants of young children’s behavioral problems and their outcomes. Failure to consider these issues in determining whether a child may have ADHD could lead to an erroneous diagnosis. Behavioral Assessment Box 1 provides simple DSM-IV-based criteria to assist in distinguishing annoying or difficult behaviors from those that are clinically significant. Numerous behavioral checklists have been devised to investigate systematically parents‘ and teachers’ perceptions of behavior, including those consistent with a diagnosis of ADHD.’, 5, l6 Concerns about extremely atypical or psychotic behavior should be explored further by a psychologist or psychiatrist. Speech pathologists are often adept in evaluations of children suspected of the autism pervasive developmental disorder spectrum because of delayed language development, poor social skills, and difficult behaviors. Cognitive and Educational Evaluations Children with cognitive delays, neurodevelopmental immaturity, or learning problems may be perceived as excessively active or inattentive, especially if expectations are inappropriate for developmental level or if there is a mismatch between the child’s capabilities and the demands in certain settings. A formal
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Box 1. Criteria That D-ifferentiate Annoying or Difficult Behaviors from Those That Are Clinically Significant The presence of a pattern or constellation of symptoms (hyperactivity, impulsivity, and/or inattention greater than that expected for age or developmental level). A pattern of symptoms that goes beyond a transient adjustment or stress or change. A cluster of symptoms that is evident in several settings and with people other than the parent(s). Symptoms are relatively severe. Symptoms reflect impairment in social and academic functioning or participation in family life.
cognitive evaluation to determine learning potential as well as an educational evaluation to determine achievement and, more importantly, learning style can be extremely helpful diagnostically as well as prescriptively. Learning disabilities cannot be identified reliably before school entry, but relative weaknesses in developmental skills can be described and remedial action initiated. Some physicians may choose to assess these skills directly. Two useful instruments for so doing are the Pediatric Assessment System (which includes the PEET for 3 year olds and the PEER for 4 to 6 year olds)= and the Early Screening In~entory.~" Because concerns about attention and behavior actually may be misinterpretations of neurodevelopmental pr0blem9,3~such evaluations as initial screenings can be helpful in deciding whether fuller investigation is warranted. Physical Examination
A general physical examination, including assessment of hearing and vision, is important to rule out diagnoses that might be relevant to behavioral disturbances. Normal in most cases, the physical examination occasionally reveals surprising findings, particularly conditions associated with ADHD-like symptoms such as the Williams or Fragile X syndromes. The examination also may reveal previously unappreciated chronic health problems, such as serious otitis media. A vision and hearing test should be included. Although behavior can be deceptively subdued for a frightened young child expecting a shot, direct observations of attention, activity level, and social interaction can be helpful. On the other hand, a child who frenetically climbs on the furniture, turns the lights and faucets off and on, and presses the nurse call button after repeated requests not to do so warrants suspicion. The receptionist often becomes quite adept at judging appropriateness of behavior in a free play setting among young children in the waiting room. MANAGEMENT
The primary components of management are counseling and behavior management and medication. Whether the problematic behaviors represent true ADHD or not, counseling for family stress and behavior management are help-
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ful. However, accurate ADHD or other behavioral diagnoses are necessary before psychopharmacologic interventions are initiated.
Family Intervention Family discord and ADHD exacerbate one another. To break this cycle, attention to family issues such as parental depression, tension and violence, and marital discord should be a starting point. Parents are often shocked when, having brought the child in for his or her problems, it is suggested that the family become involved in counseling. The child‘s difficulties cannot be addressed effectively while the family is in turmoil. At times, individual as well as group psychotherapy is necessary for the parents. Rarely is individual therapy indicated for a preschool-aged child to address hyperactivity or inattention unless there is specific comorbid psychopathology. Most often families are referred to a psychotherapist or counselor in private or community mental health settings. Although these professionals are the most highly trained to deal with family problems, limited resources or parental resistance may make such referrals difficult. Coleman and Howardls have advocated a primary care provider’s role in family counseling. However, it takes additional training, commitment, and time to assume this role effectively. Typically, parents become quite isolated because they are unable to find or trust others to care for their difficult preschool-aged child. Many parents say they have rarely, if ever, had a night out or a weekend away. Even extended family members resist the responsibility. Parent support groups such as CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorders) may be a source of empathetic socialization and potential back-up caregivers. This organization has an informative internet site (URL: http:/ /chadd.org).
Parent and Teacher Training The effectiveness of training parents in the management of their child’s 41 Almaladaptive and disordered behaviors has been well dem~nstrated.~~, though some parents may be able to learn techniques from written materials on their own, most need the guidance and support of professionals in this endeavor, especially if educational background or cognitive abilities are limited. Barkley5 has developed a particularly useful step-by-step guide to parent training entitled ”Defiant Children: A Clinician’s Manual for Assessment and Parent Training.”5 Sophisticated parents may find useful such books as “Your Hyperactive Child: A Parent’s Guide to Coping with Attention Deficit Disorder,”zo“Handbook of Parent Training: Parents as Co-Therapists for Children’s Behavior problem^,"^ and “Taking Charge of ADHD: The Complete, Authoritative Guide for parent^."^ The main emphases in parent training are on understanding the antecedents of undesirable behaviors, modifying the environment to alter those antecedents, and establishing positive incentives before using punishment. Because parental attention usually assumes a pattern of being directed exclusively toward negative behaviors, Barkley emphasizes quality attention to positive behaviors, practiced in a nondirected play session. Additional training sessions cover methods to promote compliance with reward systems, appropriate use of time out and other disciplinary methods, anticipating difficult situations, and good behavior maintenance programs. The goal is not to cure but to lessen the child’s behavior problems by enabling parents to create an environment that maximizes the
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child’s potential to behave appropriately. Sensitizing parents to how their own temperament and reactions to stress escalate behavior problems provides another avenue to improving the “fit“ between child and family.
School and Group Settings Misbehavior in preschool or child care settings is often the precipitating factor in a referral to the child’s doctor. Expulsion from such a setting is not uncommon. Behavior management techniques learned by parents are equally applicable in other settings. Communication between parents and other adults who care for their child and consistency of behavior management strategies across settings are key. Some children with ADHD qualify for preschool special education services if behavior problems are severe enough or if there are other developmental problems. Referral for evaluation by the public school system may facilitate a comprehensive look at the child and reveal resources not previously considered. Services for educational support, often encompassing ADHD, are available starting at age 3 through the local school districts. Preschool teachers may find it helpful to refer to an article by Blackman et a18 for tips on managing young children with ADHD in group settings. Similar information is also available at the following internet site: http://www.rned. virginia.edu/medicine/clinical/pediatrics/devbeh/adhdlin/phybeh~htrnl MEDICATION MANAGEMENT Without doubt the most troublesome aspect of ADHD management in preschool-aged children is the dilemma regarding the safety and appropriateness versus the possible benefits of stimulant and other psychotropic drugs. A diagnosis of ADHD usually implies that stimulant medication is part of the treatment package. Parents and teachers expect and often demand it. In older children there is little hesitation in prescribing a trial of stimulants for ADHD. However, even in clear-cut cases, many physicians loathe the idea of using such medications in young children. However, not all physicians resist the idea, as indicated in the following report. Rappley et a135studied psychotropic medication usage among young Michigan Medicaid recipients. Of individuals 3 years of age or younger identified through claims made during 1 month in 1996, 233 had a diagnosis of ADHD. Ten of these were 1 year of age or less; 50 were 2 years old. Psychotropic medications were prescribed for 57%. Psychological services were authorized for 26%; 17% received both. The youngest child medicated with psychotropics was 2 years old when the prescription was filled. Twenty-two different psychotropic agents were prescribed. In 60 instances, two or three medications were used simultaneously. Fifty-eight children were treated with two to six medications over 15 months. Methylphenidate and clonidine were the most commonly used medications, singly or in combination. Such results are likely to be representative of practices outside of Michigan. Researchers at the Massachusetts General Hospital reviewed pharmacotherapy of ADHD across the life cycle.39They found only five controlled studies of methylphenidate in preschool-aged children encompassing only 144 children. These studies reported a variable response, with improvement noted in structured tasks as well as mother-child interactions. Four of the five studies recorded a moderate to robust response; one reported a mixed response. Two of four
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studies regarding tricyclic antidepressants indicated a robust response in preschool-aged children and two reported a moderate response. They found no studies of effects of non-tricyclic antidepressants on ADHD in preschool-aged children. The studies of antipsychotic drugs are too dated and too flawed to draw useful conclusions. The results of studies on both the efficacy and side effects of methylphenidate in preschool-aged children are mixed and inconsistent. Cohen et all4 concluded that psychostimulant drugs appear to be of less certain benefit in the treatment of preschool-aged hyperactive children than with their school-aged counterparts. In contrast, Mayes et alz7found that preschool-aged children with ADHD actually had a better response to methylphenidate than school-aged children. Furthermore, they found that there was no higher frequency of side effects as a function of lower age. Results from Firestone et all9 indicated that methylphenidate has a low toxicity in preschool-aged children but the rate of short-term side effects, mostly mild, is higher in this age group. Some side effects were associated with improvements in behavior. In an older study by Schleifer et a1,38most mothers of preschool-aged children opted not to continue with medication because of disturbing side effects. Among children ages 4 to 6 with ADHD, Musten et a131found improvements on cognitive tests of attention and impulsivity as well as behaviors assessed by parent rating scales with doses of either 0.3 or 0.5 mg/kg of methylphenidate twice per day. Side effects increased at the higher dosage. Interestingly and importantly for this age group, no changes were obtained with respect to the children’s tendencies to comply with parental requests (often a chief reason children are referred for evaluation in the first place). In an earlier study, however, Barkley? found that preschool-aged children on -a dose of 0.5 mg/kg significantly increased rates of compliance with maternal commands. There has been renewed interest in clonidine (an a,-noradrenergic agonist) in recent years for treatment of behavior problems, including ADHD. It is often considered when an alternative to stimulants is necessary or in cases of overaroused, explosive-type symptoms. The few studies that have included children as young as 3 years of age have reported consistently positive responses (less on cognition than behavior) with doses in the 0.025 to 0.16 mg range. Sedation, potential hypotension (rebound hypertension if discontinued precipitously), and small pill size are the main problems with clonidine. One study of a similarly acting type of drug, guanfacine (Tenex) also showed a positive response in children from age 4.39 The minimal information that exists suggests that stimulants, specifically methylphenidate, and clonidine are useful and generally safe if prescribed and monitored appropriately in children as young as 3 years old (Table 1).However, there are insufficient data to draw conclusions about the safety of these drugs in children younger than 3 years of age or about the safety and efficacy of other psychotropic agents, such as buspirone, risperidone, or selective serotonin reuptake inhibitors in preschool-aged children with ADHD. There may be a place for these medications when comorbid conditions exist for which they are specifically indicated. However, until primary care physicians gain more expertise and experience with these newer drugs, it may be wisest to refer children to a child psychiatrist, neurologist, or developmental pediatrician for complicated medication management. Double-blinded, placebo-controlled trials of stimulant medication may be particularly useful for preschool-aged children in determining and demonstrating risk versus benefit. Although somewhat cumbersome and time consuming to organize, this approach has been shown to work well for older children in
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Table 1. STIMULANTS AND CLONlDlNE FOR PRESCHOOL CHILDREN WITH ADHD Starting Drug
Dose
methylphenidate
2.5 mg
AM
dextroamphetamine
2.5 mg
AM
clonidine
0.025-0.05 mg hs
Increase Dose by 2.5 mg if needed in 3-5 days; then 2 or 3 times a day 2.5 mg if needed in 3-5 days; then 2 or 3 times a day twice daily in 5-7 days; three times daily in 5-7 days; then slowly by 0.025-0.05 mg/d to max of 0.1 mg/dose*
Onset of Action
Duration of Action
15-30 min
2-4 h
15-30 min
3-6 h
1-2 wk
N/A
hs = bedtime. 'Titrate slowly to minimize somnolence. Monitor blood pressure and heart rate initially and with each increased dose. To discontinue, wean over 1 week to avoid rebound hypertension. A transdermal clonidine patch is available for daily doses of 0.1, 0.2, or 0.3 mg/d and lasts 7 days.
identifying true responders to medication (at least in older children) and may provide support for either recommending or, perhaps more importantly, not recommending medi~ation.'~, 21 SUMMARY
The diagnosis of ADHD in preschool-aged children is difficult. High activity level, impulsivity, and short attention span-to a degree-are age-appropriate characteristics of normal preschool-aged children. However, excessive levels of these characteristics impede successful socialization, optimal learning, and positive parent-child interaction. Environmental stressors, inadequate parenting skills, and other diagnoses such as oppositional defiant, posttraumatic stress, or adjustment disorders can mimic ADHD. Although labeling may be necessary to obtain services, the emphasis should be placed on symptom resolution, given the uncertainties of diagnostic accuracy in this age group. Deferring a specific diagnosis of ADHD until confounding issues are clarified should be considered. The evaluation of serious behavior problems in young children must include a comprehensive consideration of environmental, health, cognitive, educational, and behavioral interactions. Both assessment and intervention should focus on the interactions between the child and his or her environment to determine how they facilitate or hinder adaptive integration as both the child and surroundings change and evolve. Treatment invariably necessitates involvement of a child and family psychotherapist or counselor to address behavior management strategies as well as family dynamics, parental psychopathology, or life stress. Parents must understand that counseling is an essential component of treatment and that they must be active participants. Psychopharmacologic intervention may be appropriate in some instances, although conventional wisdom suggests caution in young children, given the limited information about safety and efficacy of many agents, especially in
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children younger than 3 years old. Stimulants appear to be safe in older preschool-aged children. Children started on medication should be monitored closely for both positive and negative effects. A double-blinded, placebo-controlled trial of medication is warranted in equivocal situations.*
References 1. Achenbach TM: Child Behavior Checklist: Cross-Informant Version. Burliigton, VT, Thomas Achenbach, 1991 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, DC, American Psychiatric Association, 1994 3. Barkley RA: The effects of methylphenidate on the interactions of preschool ADHD children with their mothers. J Am Acad Child Adolesc Psychiatry 27336, 1988 4. Barkley RA: Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. New York, Guilford Press, 1995 5. Barkley RA: Defiant Children: A Clinician’s Manual for Assessment and Parent Training. New York, Guilford Press, 1997 6. Beitchman JH, Wekerle C, Hood J: Diagnostic continuity from preschool to middle childhood. J Am Acad Child Adolesc Psychiatry 26:694, 1987 7. Blackman JA, Levine M D A follow-up study of preschool children evaluated for developmental and behavioral problems. Clin Pediatr 26:248, 1987 8. Blackman JA, Westervelt VD, Stevenson R, et al: Management of preschool children with attention deficit-hyperactivity disorder. Topics in Early Childhood Special Education 11:91, 1991 9. Briesmeister JM, Schaefer CE: Handbook of Parent Training: Parents a$ Co-Therapists for Children’s Behavior Problems. New York, John Wiley & Sons, 1997 10. Campbell SB Behavior problems in preschool children: A review of recent research. J Child Psychol Psychiatry 36:113, 1995 11. Campbell SB, Ewing LJ: Hard-to-manage preschoolers: Adjustment at age nine and predictors of continuing symptoms. J Child Psychol Psychiatry 31:871, 1990 12. Campbell SB, Ewing LJ, Breaux AM, et al: Parent-identified behavior problem toddlers: Follow-up at school entry. J Child Psychol Psychiatry 37:473, 1996 13. Campbell SB, Pierce EW, March CL, et al: Hard-to-manage preschool boys: Symptomatic behavior across contexts and time. Child Dev 655336, 1994 14. Cohen NJ, Sullivan J, Minde K, et al: Evaluation of the relative effectiveness of methylphenidate and cognitive behavior modification in the treatment of kindergartenaged hyperactive children. J Abnorm Child Psychol 9:43, 1981 15. Coleman WL, Howard BJ: Family-focused behavioral pediatrics: Clinical techniques for primary care. Pediatr Rev 16:448, 1995 16. Conners C K Conners Parent and Teacher Rating Scales. North Tonawanda, NY, MultiHealth Systems, 1989 17. DiTraglia J: Methylphenidate protocol: Feasibility in a pediatric practice. Clin Pediatr 30:656, 1991 18. Egeland B, Kalkoske M, Gottesman N, et al: Preschool behavior problems: Stability and factors accounting for change. J Child Psychol Psychiatry 31:891, 1990 19. Firestone P, Musten LM, Pisterman S, et al: Short-term side effects of stimulant medication are increased in preschool children with attention-deficit/hyperactivity disorder; A double-blind placebo-controlled study. Journal of Child and Adolescent Pschopharmacology 8:13, 1998 “Personal computer software, developed with support from the US Department of Education, National Institute on Disability and Rehabilitation Research (Award # H133G50148), to facilitate the conduct of a double-blinded, placebo-controlled individual trial of stimulant medication in a primary care practice or clinic is available from the author at the following address: Kluge Children’s Rehabilitation Center, University of Virginia, 2270 Ivy Road, Charlottesville, VA 22901, USA. E-mail: [email protected].
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20. Ingersoll B: Your Hyperactive Child: A Parent’s Guide to Coping with Attention Deficit Disorder. New York, Main Street Books, 1988 21. Kamien M The use of an N-of-1 randomized clinical trial in resolving therapeutic doubt: The case of a patient with an attention disorder. Aust Fam Physician 27(suppl):103, 1998 22. Kaplan BJ, McNicol J, Conte RA, et al: Physical signs and symptoms in preschool-age hyperactive and normal children. Developmental and Behavioral Pediatrics 8:305, 1987 23. Kaplan BJ, McNicol J, Conte RA, et al: Sleep disturbance in preschool-aged hyperactive and nonhyperactive children. Pediatrics 80:839, 1987 24. Lemer JA, Inui TS, Trupin EW, et al: Preschool behavior can predict future psychiatric disorders. J Am Acad Child Adolesc Psychiatry 2442, 1985 25. Levine MD. Pediatric Assessment System. Cambridge, MA, Educators Publishing Service, 1988 26. Levine MD: ANSER System. Cambridge, MA, Educators Publishing Service, 1996 27. Mayes SD, Crites DL, Bixler EO, et al: Methylphenidate and ADHD Influence of age, IQ, and neurodevelopmental status. Dev Med Child Neurol 36:1099, 1994 28. McGee R, Partridge F, Williams S, et al: A twelve-year follow-up of preschool hyperactive children. J Am Acad Child Adolesc Psychiatry 30224, 1991 29. McGee R, Williams S, Feehan M: Attention deficit disorder and age of onset of problem behaviors. J Abnorm Child Psychol 20:487, 1992 30. Meisels S, Marsden D, Wiske MS, et a1 Early Screening Inventory, Revised. Ann Arbor, MI, Rebus, 1997 31. Musten LM, Firestone P, Pisterman S, et al: Effects of methylphenidate on preschool children with ADHD. Cognitive and behavioral functions. J Am Acad Child Adolesc Psychiatry 36:1407, 1997 32. Oberklaid F, Dworkin PH, Levine MDf Developmental-behavioral dysfunction in preschool children: Descriptive analysis of a pediatric consultative model. Am J Dis Child 133:1126, 1979 33. Palfrey JS, Levine MD, Walker DK, et al: The emergence of attention deficits in early childhood: A prospective study. Developmental and Behavioral Pediatrics 6339, 1985 34. Pisterman S, McGrath P, Firestone P, et a1 Outcome of parent-mediated treatment of preschoolers with attention deficit disorder with hyperactivity. J Consult Clin Psychol 57:628, 1989 35. Rappley MD, Mullan PB, Gardiner JC, et al: Attention deficit hyperactivity disorder and the use of psychotropic medication in very young children. Arch Pediatr Adolesc Med, in press 36. Reeves JC, Werry JS, Elkind GS, et al: Attention deficit, conduct, oppositional, and anxiety disorders in children: 11. Clinical characteristics. J Am Acad Child Adolesc Psychiatry 26:144,1987 37. Rosenberg MS, Wilson RJ, Legenhausen E: The assessment of hyperactivity in preschool populations: A multidisciplinary perspective. Topics in Early Childhood Special Education 990, 1989 38. Schleifer M, Weiss G, Cohen N, et al: Hyperactivity in preschoolers and the effect of methylphenidate. Am J Orthopsychiatry 45:38, 1975 39. Spencer T, Biederman J, Wilens T, et al: Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc Psychiatry 35:409, 1996 40. Stormont-Spurgin M, Zentall SS: Contributing factors in the manifestation of aggression in preschoolers with hyperactivity. J Child Psychol Psychiatry 36:491, 1995 41. Strayhom JM, Weidman C S Reduction of attention deficit and internalizing symptoms in preschoolers through parent-child interaction training. J Am Acad Child Adolesc Psychiatry 28:888, 1989
Address reprint requests to James A. Blackman, MD, MPH Kluge Children’s Rehabilitation Center 2270 Ivy Road Charlottesville, VA 22903
0031-3955/99 $8.00
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ATTENTION-DEFICIT / HYPERACTIVITY DISORDER IN PRESCHOOLERS Does It Exist and Should We Treat It? James A. Blackman, MD, MPH
Marvin, 4 years old, has just been expelled from preschool for aggressive behavior. Carolyn, 2.5 years old, is so motorically wound up that she takes no naps, finally falls asleep at 11:OO PM, and awakens at 6:OO AM. Leah, 3 years old, cannot be trusted to play unsupervised. She has been to the emergency department three times for toxic ingestions and pushed the new puppy off the bed, dislocating its hind limb. Two weeks after his second birthday, Kelly’s longedfor toys are already broken. Rarely did his interest in any one of them last for more than a few minutes. The parents of these young children are exasperated, tired, embarrassed, and sometimes fearful. At these ages they are most likely to turn to their child’s primary care physician for help. Some parents already have a specific agenda: they want medication to control the hyperactivity and impulsiveness, regardless of the child’s age. Others are more open, perhaps naive initially, and seek a better understanding of their child’s behavior as well as various options for management. Each of these children might warrant a diagnosis of attention-deficit/hyperactivity ’disorder (ADHD). However, their behaviors are also consistent with a variety of other diagnoses, including normal behavior for age or developmental level. Distinguishing between the possibilities and making the medically and ethically correct decisions are exceedingly challenging in early childhood. The purpose of this article is to review the literature regarding the diagnosis and management of ADHD in preschool-aged children and to offer specific
From the Division of Developmental Pediatrics, University of Virginia; and Kluge Children’s Rehabilitation Center, University of Virginia, Charlottesville, Virginia
PEDIATRIC CLINICS OF NORTH AMERICA ~
VOLUME 46 * NUMBER 5 * OCTOBER 1999
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strategies for approaching this formidable challenge in pediatric practice based on this review, personal experience, and the experience of colleagues. NATURE OF THE PROBLEM The essential features of ADHD-inattention, impulsivity, and hyperactivity-are apt descriptors of the behavior of most preschool-aged children at one time or another. Activity and attention vary with age and developmental level. The DSM-IV2 states that toddlers and preschoolers with ADHD "differ from normally active young children by being constantly on the go and into everything. They dart back and forth, are out the door before their coat is on, jump or climb on furniture, run through the house, and have difficulty participating in sedentary group activities in preschool classes (e.g., listening to a story)." A child with ADHD has difficulty playing alone for more than a short time, destroys rather than plays with toys, and may have few friends because of aggression and inability to cooperate in play. High activity rather than inattention is likely to be the symptom most noticeable in preschool-aged children. However, inattention and impulsivity are evident in the child's carelessness, failure to complete tasks, and difficulties following instructions. Even the attention of toddlers can be held in a variety of situations (e.g., the average 2- to 3-year-old child typically can sit with an adult to look through picture books). In contrast, young children with ADHD move excessively and typically are difficult to contain.z Certainty in the diagnosis of ADHD in preschoolers is difficult because of the day-to-day variability of behavior, situational responses to the environment, and adult interpretations of behavior. Children may be revved one day, placid the next. At indulgent Grandma's or at a sensory-overloading supermarket they may be uncontrollable, whereas at a structured day care setting they are compliant. Mom, who is exhausted from her son Charlie's insatiable demands, sees him as "hyper," Dad's interpretation of Charlie's behavior, when he is home on weekends from his long-haul trucking runs, is that he's "all boy," just like he was when he was a kid. Additional common manifestations of ADHD-aggression, noncompliance, and social ineffectiveness-may be confused with other diagnoses such as oppositional defiant disorder or difficult temperament. Of 105 children studied for disruptive behavior disorders by Reeves et a1,= fewer than half received only one diagnosis. Conduct and oppositional defiant disorders resembled each other and seldom occurred in the absence of ADHD. It is difficult to differentiate ADHD in toddlers from other discipline problems at this age. Some children simply have never learned limits, rules of behavior, or empathy. If ADHD is truly biologically based, it should be manifested from birth. For most young children, however, suspicions about ADHD do not arise until they are 2 or 3 years old. In a prospective longitudinal study by Palfrey et al,33 no infants less than 14 months of age were found to have definite concerns about attention or hyperactivity on a behavior impressions summary, and only 3% had possible concerns expressed by parents. Between the ages of 14 and 29 months of age, 13% of the study group met criteria for definite or possible concerns. The researchers suggested that this dramatic increase occurred because infants may not be confronted with the kinds of experiences and tasks that dramatize and bring forth these symptoms. As young children enter a structured preschool experience, it may be the first time in their lives when they are expected to fit into externally imposed structures, behave in socially acceptable ways, relate to peers socially, and conform to the authority of adults other than parents.
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Why does it matter whether ADHD is diagnosed before school age? Perhaps the chief pressure for making an early diagnosis is to obtain supportive services. It is unfortunate but realistic that a medical sounding label such as ADHD often qualifies for insurance reimbursement, at least for initial evaluation and sometimes short-term behavioral therapy, whereas other terms such as adjustment reaction or simply behavior problems do not. In many states, ADHD is an eligible medical diagnosis for inclusion in either early intervention or preschool special education programs under the Individuals with Disabilities Education Act (IDEA). School programs may accept ADHD as a qualifier for special educational services but not merely difficult behavior. A specific label that most parents and teachers have heard of provides a certain relief that the problem is the child’s, not the parents’, and that there is hope of a cure through medication. Most parents (backed by teachers) of problematic preschoolers leave the office happier with a firm diagnosis of ADHD than with a “Maybe,” ”We’re not sure,” “It’s too early to tell,” or “Probably not.” Determined parents may shop for a doctor until they find one who gives them the diagnosis and treatment they want. An accurate diagnosis of ADHD clearly points to the appropriate remedial action that should take place. Many preschool teachers are familiar with behavior management strategies or have access to consultants who can assist them with reward systems, classroom modifications, and time out procedures. Parents can walk into any bookstore and find useful ADHD materials for home use. Judiciously and selectively considered, medications are helpful, sometimes dramatically, in conjunction with parent counseling. Delaying the diagnosis may delay interventions that might prevent worsening of behaviors or secondary problems with self-esteem, socialization, and learning. On the other hand, there are clear dangers to early labeling, the most important of which is inappropriate labeling. In the next section, a review of longitudinal follow-up studies demonstrates the difficulties in making an accurate diagnosis in the early years of life. Even if the diagnosis is dismissed at a later age, the term ADHD remains in the medical record, to be distributed to and reviewed by numerous individuals and agencies. Any label, particularly one as loaded as ADHD, is hard to lose once attained. When the word is out that Torrance has ADHD, Torrance is the last to be chosen for the little league team, is unwelcome at other kids’ homes, and is the first one to be implicated in a disturbance in the classroom. Underachievement may be accepted as part of the syndrome. Unfortunately, the reputation usually persists, even if the diagnosis is removed. The most controversial aspect of early diagnosis of ADHD is the issue of medication. It is well accepted that stimulants and other medications are an effective and integral part of treatment for ADHD, especially when used with behavior management training. Parents and teachers beg for, demand, and expect medication for an ADHD diagnosis. Resistance to prescribing medication on the part of the physician, even with young children in whom the safety of stimulants is uncertain, is interpreted as insensitive and obstructionistic. To many, it appears illogical for a physician to make a diagnosis of ADHD then refuse to prescribe a medication to treat it. NATURAL HISTORY OF ADHD PROBLEMS
The key to deciding whether ADHD can be diagnosed confidently before school age lies with longitudinal studies. Although not plentiful, there exists important and fairly consistent information in the literature to guide such a consideration. Follow-up studies have helped to distinguish which children with
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which types of behaviors in which environments will have persistent problems at an age when a definite diagnosis is possible. In a short-term study at the Children’s Hospital in Boston, we found that only half of parents of preschool-aged children evaluated for behavior problems, including hyperactivity and inattention, continued to be concerned 1 to 2 years later, although in many of the cases teachers continued to be ~oncerned.~ Children with persistent problems tended to have difficult temperamental characteristics, such as high intensity of affective expression, difficulties with changes in routine, low sensory threshold, and arhythmicity of biologic functions. Lerner et alZ4followed 88 problem preschoolers for an average of 11.5 years and found that those children with high ratings of overall behavioral disturbance (based on chart review and formal interview using the diagnostic interview for children and adolescents) had at least twice the risk for the development of a future psychiatric disorder compared with less dysfunctional children. Initial behavior problems included verbal and physical aggression, hyperactivity or distractibility, and social withdrawal. Subjects in this study came from welleducated, middle-class families and had above-average IQs. As part of Harvard University’s Brookline Early Education Project, Palfrey et aP3 followed 174 children prospectively from birth to second grade for the emergence, persistence, and disappearance of behavioral difficulties, including attentional problems. Over the period from birth to kindergarten, 40% of the preschool children were found to have some attentional indicator, but many of the findings were minor or transient. Persistent attentional problems were identified in 5% of the children; 8% had significant problems that abated before kindergarten. The investigators found that concomitant social-emotional problems ( e g , difficulty relating to peers, fearfulness, acting out behaviors) and delays in motor function signaled a more malignant form of attention deficit that is likely to persist. Conversely, resilience, evident by abatement of attentional difficulties, was associated with higher maternal education level, greater family stability, fewer health problems, higher general cognitive ability, and stronger verbal ability. Similarly, Egeland et aPSfound that improved behavioral functioning between preschool and elementary school appeared to be related to low stress at home, higher quality of the home environment, and low levels of maternal depression. Beitchman et a16 reported on a diagnostic and symptom outcome study of 98 children who attended a therapeutic preschool program in Toronto. Children were admitted to this program with behavior problems severe enough to warrant a comprehensive approach to treatment that included individual psychotherapy, supplemental developmental support activities, and family counseling. The sample consisted of 84% boys, with age ranges of 2.5 to 6 years. The average interval of follow-up was 5 years after discharge from the program. Approximately half the children were from intact families, one third from single parent families. The remainder was with stepparents or in foster homes. The average IQ of the initial sample was 90 on the Stanford-Binet Intelligence Scale. Sixty-nine percent of the children seen at follow-up were found to have diagnosable DSM-I11 disorders, compared with 90% at initial assessment. Thus, although there was some improvement in the 5 years since discharge from the preschool, a substantial number of children continued to show evidence of a DSM-111 disorder. In most instances the DSM-111 disorder was the same at follow-up as it was initially. The diagnostic groups that showed the greatest stability in behavior over the 5-year period were those with developmental delay or attention deficit disorder or both. The group with conduct disorder showed only moderate stability. In contrast, the children with emotional disorders received similar diagnoses only 29% of the time, reflecting the lowest level of diagnostic continuity.
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Of 1037 children followed from age 3 to age 15 in the Dunedin Multidisciplinary Health and Development Study, 2% (13 boys and 8 girls) were identified as "pervasively hyperactive" initiallyz8 Compared with nonhyperactive preschoolers, these children more often came from families with high levels of adversity, and they showed poorer language skills. Over a 12-year follow-up period, the hyperactive preschoolers continued to show significantly poorer cognitive skills, lower levels of reading ability, disruptive and inattentive behaviors at home and at school, and higher rates of DSM-I11 disorders of preadolescence and adolescence than comparison children. By age 15, only one fourth of this group was identified as having met full recovery criteria. However, only 2 of the original group of hyperactive children received the diagnosis of attentiondeficit disorder (ADD). (Author note: ADD rather than ADHD is used in those instances in which ADD was the terminology used in the study report). The importance of this study is that it was conducted on a nonreferred population of children and thus provides a more naturalistic view of behavior problems among preschool-aged children and their outcomes. In subsequent analysis of the Dunedin data, researchers reported that the earlier the onset of ADD symptoms, the more likely behavioral and developmental morbidity would persistz9 Campbell et allz followed hard-to-manage preschool-aged children recruited at age 3 and 4 identified by parent complaints of inattention, overactivity, and discipline problems. At age 6 only 50% of the group met criteria for ADD or were perceived by parents to have significant problems. At age 9, 48% met DSM-I11 criteria for an externalizing disorder (ADD and/or oppositional defiant disorder or conduct disorder) compared with 16% of comparison children." These studies indicate that serious problems with aggression and impulse control during the preschool years, overlapping with attentional problems, often persist to school entry and beyond. Such difficulties may be exacerbated when the family environment is more chaotic and less supportive and when parents themselves do not foster their young child's self-regulation and behavioral contr01.'~However, it is important to recognize that for half of the preschoolaged children with these problems, symptoms are transient and eventually abate. Distinguishing between these groups and selecting those with ADHD is the challenge. Accumulating evidence suggests that preschool-aged children are more likely to show overactive, noncompliant, aggressive, and impulsive behavior in the context of uninvolved, rejecting, or harsh parenting. On the other hand, warmth, responsiveness, and appropriate limit setting foster the development of more socially competent behavior in young children. The absence of these qualities of parenting or overt rejection and negative control are likely to be associated with persistent problems. The onset of problems is often associated with emerging family difficulties, whereas amelioration of problems is often associated with improvement in the quality of family relationships. It appears likely that biologic tendencies in the child interact with the caregiving environment to produce either adaptive or maladaptive outcomes that may vary at different developmental transition points.'" These observations raise the possibility that early recognition of problems, regardless of what label is used, and appropriate interventions, particularly in the psychosocial sphere, have the potential of averting or at least ameliorating future problems. ORIGIN OF ADHD IN PRESCHOOL-AGEDCHILDREN
The title of this section should more properly read the etiology of ADHDlike symptoms in preschool-aged children. That true ADHD exists and can be
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detected in this age group is beyond doubt. The problem is that multiple etiologies lead to similar symptomotology (Fig. 1).Both neurologic and genetic factors have been implicated in the causation of ADHD. Acquired brain injury, prenatal exposure to toxins such as alcohol, and perinatal complications including preterm birth and birth asphyxia have been associated with ADHD. Clearly, ADHD runs in families, supporting the inheritable nature of ADHD. Genetic factors seem to account for most cases of ADHD. In some cases, a genetic predisposition toward ADHD may be exacerbated by brain injury. Although psychosocial and environmental factors are no longer believed to cause ADHD, such factors can lead to behaviors that mimic ADHD. Chaos or stability in the life of a child with ADHD either exacerbates or ameliorates the expression of symptoms. In Campbell's study of difficult-to-manage preschoolaged boys who were rated as overactive, inattentive, and impulsive by teachers, problems were most likely to persist when symptoms were severe and mothers were negative and controlling and family stress was more severe and chronic." In less stressful family settings in which mothers were more patient and less negative, boys with the same initial behavioral characteristics had fewer problems at follow-up. A group of comparison boys without problems at first but living in dysfunctional family settings developed problems at age 6. Finally, boys with low levels of initial problems living in normal family environments remained symptom free. These observations have obvious implications for intervention to be discussed later. Preschoolers who manifest aggression in addition to hyperactivity are particularly problematic. Such children have been found to have families whose fathers are highly restrictive, mothers who report both giving verbal and receiving physical aggression, and siblings who retaliate aggres~ively.~~ Persistent Psychosocial stressors Chronic disease \
I
Syndromes (e.g.:Williams)
Information
ADHD
Medication
INATTENTION IMPULSIVITY HIGH ACTIVITY LEVEL defiant disorder
Emerging conduct disorder
I
Mental retardation
caregivers Figure 1. Differential diagnosis for ADHD-like symptoms in preschool children.
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aggressive behavior was predicted by initial child unmanageability, maternal depression, perceived lack of support, and low income. ASSESSMENT APPROACH Because the diagnosis of ADHD is so difficult in preschool-aged children, the goal of assessment should be on relief of symptoms rather than on a specific diagnosis. In some instances, specific diagnoses are obvious and necessary for obtaining services or reimbursement or both. However, a diagnostic label should not imply that the problem is exclusively within the child or must inevitably lead to drug regimens. Because a physician must make judgments about prescribing medication or behavioral therapies, he or she is ethically obligated to be as certain as possible that, based on a thorough evaluation, the child is being appropriately diagnosed. Assessment should be multidimensional, considering all possible explanations for a child’s hyperactive, inattentive, impulsive, aggressive, or noncompliant behavior (Fig. 1). Such an approach must integrate physical, emotional, cognitive, and ecologic information about the Although this wide perspective may be attainable by one individual in some circumstances, more likely an interdisciplinaryevaluation will be necessary, implemented through a variety of possible models. The child’s primary care physician is the most likely individual to whom parents bring their concerns or those of their child’s preschool teacher or day care provider. At a minimum, the physician should conduct a brief interview and examination of the child to determine whether the behavior problems are transient and easily attributable to a specific causative factor or whether they are chronic and warrant a more thorough and detailed evaluation. Unless a particular case seems clear and straightforward, the physician would be well advised to consult with specialists in child psychology and early childhood education. The primary care physician might serve as the coordinator of the evaluations in the community (involving the school, community mental health agency, or private consultants) or refer a child to a developmental evaluation center for an initial assessment, thereafter assuming responsibility for ongoing treatment and follow-up. For a familiar child who has been followed in primary care since birth, symptom evolution, family history, and the environmental context may be so clear that a diagnosis of ADHD is straightforward without extensive consultation. For a new child, however, a broader assessment is essential. Health History A general medical history is obtained to identify risk factors for ADHD or other behavior problems and to rule out any health problems that might mimic ADHD or influence behavior. Biologic risk factors such as prematurity and fetal alcohol exposure are probably more useful for research than in individual cases. If a child has problems, risk factors are somewhat irrelevant. However, coupled with a family history, positive findings increase the likelihood of an endogenous component to the behavior problems. Absence epilepsy would be an unlikely and obvious cause of attentional lapses in this age group. Some anticonvulsant medications, notably phenobarbital, commonly make young children hyperactive. Allergies are significant, not
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because they have been found to cause ADHD but because chronic nasal congestion may result in restless sleep or decongestants and antihistamines may produce behavioral disturbances. Other chronic diseases and their treatments should be explored as well for their potential impact on behavior. Parents of preschool-aged hyperactive children report higher rates of physical complaints such as bad breath, skin rashes, red cheeks, stomach bloating, stuffy and runny noses, and leg cramps than parents of non-ADHD childrenz2 Sleep problems have been cited frequently as common in ADHD. However, Kaplan et alZ3did not find differences in total sleep time or sleep onset latency between preschool-aged hyperactive and nonhyperactive children, although there was an increase in the frequency of night wakenings for the hyperactive group. These night awakenings disturb parents’ sleep; thus, they may report that these children are poor sleepers.23 The ANSER System is one method designed for health care settings that uses questionnaires completed by parents and preschool personnel to gather health, developmental, and behavioral information in a systematic manner.26 Specific versions of these questionnaires are available for preschool-aged children. Psychosocial Evaluation Primary care physicians often have an advantage of knowing families well and the environment in which the child lives. However, when.such information is not known, an in-depth interview is essential to explore such issues as family stresses, marital relations, violence, housing, and financial conditions. A psychologist or social worker is likely to obtain more information and provide valuable interpretation of the material. From Campbell’s work described earlier, family stresses and problems are significant determinants of young children’s behavioral problems and their outcomes. Failure to consider these issues in determining whether a child may have ADHD could lead to an erroneous diagnosis. Behavioral Assessment Box 1 provides simple DSM-IV-based criteria to assist in distinguishing annoying or difficult behaviors from those that are clinically significant. Numerous behavioral checklists have been devised to investigate systematically parents‘ and teachers’ perceptions of behavior, including those consistent with a diagnosis of ADHD.’, 5, l6 Concerns about extremely atypical or psychotic behavior should be explored further by a psychologist or psychiatrist. Speech pathologists are often adept in evaluations of children suspected of the autism pervasive developmental disorder spectrum because of delayed language development, poor social skills, and difficult behaviors. Cognitive and Educational Evaluations Children with cognitive delays, neurodevelopmental immaturity, or learning problems may be perceived as excessively active or inattentive, especially if expectations are inappropriate for developmental level or if there is a mismatch between the child’s capabilities and the demands in certain settings. A formal
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Box 1. Criteria That D-ifferentiate Annoying or Difficult Behaviors from Those That Are Clinically Significant The presence of a pattern or constellation of symptoms (hyperactivity, impulsivity, and/or inattention greater than that expected for age or developmental level). A pattern of symptoms that goes beyond a transient adjustment or stress or change. A cluster of symptoms that is evident in several settings and with people other than the parent(s). Symptoms are relatively severe. Symptoms reflect impairment in social and academic functioning or participation in family life.
cognitive evaluation to determine learning potential as well as an educational evaluation to determine achievement and, more importantly, learning style can be extremely helpful diagnostically as well as prescriptively. Learning disabilities cannot be identified reliably before school entry, but relative weaknesses in developmental skills can be described and remedial action initiated. Some physicians may choose to assess these skills directly. Two useful instruments for so doing are the Pediatric Assessment System (which includes the PEET for 3 year olds and the PEER for 4 to 6 year olds)= and the Early Screening In~entory.~" Because concerns about attention and behavior actually may be misinterpretations of neurodevelopmental pr0blem9,3~such evaluations as initial screenings can be helpful in deciding whether fuller investigation is warranted. Physical Examination
A general physical examination, including assessment of hearing and vision, is important to rule out diagnoses that might be relevant to behavioral disturbances. Normal in most cases, the physical examination occasionally reveals surprising findings, particularly conditions associated with ADHD-like symptoms such as the Williams or Fragile X syndromes. The examination also may reveal previously unappreciated chronic health problems, such as serious otitis media. A vision and hearing test should be included. Although behavior can be deceptively subdued for a frightened young child expecting a shot, direct observations of attention, activity level, and social interaction can be helpful. On the other hand, a child who frenetically climbs on the furniture, turns the lights and faucets off and on, and presses the nurse call button after repeated requests not to do so warrants suspicion. The receptionist often becomes quite adept at judging appropriateness of behavior in a free play setting among young children in the waiting room. MANAGEMENT
The primary components of management are counseling and behavior management and medication. Whether the problematic behaviors represent true ADHD or not, counseling for family stress and behavior management are help-
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ful. However, accurate ADHD or other behavioral diagnoses are necessary before psychopharmacologic interventions are initiated.
Family Intervention Family discord and ADHD exacerbate one another. To break this cycle, attention to family issues such as parental depression, tension and violence, and marital discord should be a starting point. Parents are often shocked when, having brought the child in for his or her problems, it is suggested that the family become involved in counseling. The child‘s difficulties cannot be addressed effectively while the family is in turmoil. At times, individual as well as group psychotherapy is necessary for the parents. Rarely is individual therapy indicated for a preschool-aged child to address hyperactivity or inattention unless there is specific comorbid psychopathology. Most often families are referred to a psychotherapist or counselor in private or community mental health settings. Although these professionals are the most highly trained to deal with family problems, limited resources or parental resistance may make such referrals difficult. Coleman and Howardls have advocated a primary care provider’s role in family counseling. However, it takes additional training, commitment, and time to assume this role effectively. Typically, parents become quite isolated because they are unable to find or trust others to care for their difficult preschool-aged child. Many parents say they have rarely, if ever, had a night out or a weekend away. Even extended family members resist the responsibility. Parent support groups such as CHADD (Children and Adults with Attention Deficit/Hyperactivity Disorders) may be a source of empathetic socialization and potential back-up caregivers. This organization has an informative internet site (URL: http:/ /chadd.org).
Parent and Teacher Training The effectiveness of training parents in the management of their child’s 41 Almaladaptive and disordered behaviors has been well dem~nstrated.~~, though some parents may be able to learn techniques from written materials on their own, most need the guidance and support of professionals in this endeavor, especially if educational background or cognitive abilities are limited. Barkley5 has developed a particularly useful step-by-step guide to parent training entitled ”Defiant Children: A Clinician’s Manual for Assessment and Parent Training.”5 Sophisticated parents may find useful such books as “Your Hyperactive Child: A Parent’s Guide to Coping with Attention Deficit Disorder,”zo“Handbook of Parent Training: Parents as Co-Therapists for Children’s Behavior problem^,"^ and “Taking Charge of ADHD: The Complete, Authoritative Guide for parent^."^ The main emphases in parent training are on understanding the antecedents of undesirable behaviors, modifying the environment to alter those antecedents, and establishing positive incentives before using punishment. Because parental attention usually assumes a pattern of being directed exclusively toward negative behaviors, Barkley emphasizes quality attention to positive behaviors, practiced in a nondirected play session. Additional training sessions cover methods to promote compliance with reward systems, appropriate use of time out and other disciplinary methods, anticipating difficult situations, and good behavior maintenance programs. The goal is not to cure but to lessen the child’s behavior problems by enabling parents to create an environment that maximizes the
ATTENTION’DEFICIT HYPERACTIVITY DISORDER IN PRESCHOOLERS
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child’s potential to behave appropriately. Sensitizing parents to how their own temperament and reactions to stress escalate behavior problems provides another avenue to improving the “fit“ between child and family.
School and Group Settings Misbehavior in preschool or child care settings is often the precipitating factor in a referral to the child’s doctor. Expulsion from such a setting is not uncommon. Behavior management techniques learned by parents are equally applicable in other settings. Communication between parents and other adults who care for their child and consistency of behavior management strategies across settings are key. Some children with ADHD qualify for preschool special education services if behavior problems are severe enough or if there are other developmental problems. Referral for evaluation by the public school system may facilitate a comprehensive look at the child and reveal resources not previously considered. Services for educational support, often encompassing ADHD, are available starting at age 3 through the local school districts. Preschool teachers may find it helpful to refer to an article by Blackman et a18 for tips on managing young children with ADHD in group settings. Similar information is also available at the following internet site: http://www.rned. virginia.edu/medicine/clinical/pediatrics/devbeh/adhdlin/phybeh~htrnl MEDICATION MANAGEMENT Without doubt the most troublesome aspect of ADHD management in preschool-aged children is the dilemma regarding the safety and appropriateness versus the possible benefits of stimulant and other psychotropic drugs. A diagnosis of ADHD usually implies that stimulant medication is part of the treatment package. Parents and teachers expect and often demand it. In older children there is little hesitation in prescribing a trial of stimulants for ADHD. However, even in clear-cut cases, many physicians loathe the idea of using such medications in young children. However, not all physicians resist the idea, as indicated in the following report. Rappley et a135studied psychotropic medication usage among young Michigan Medicaid recipients. Of individuals 3 years of age or younger identified through claims made during 1 month in 1996, 233 had a diagnosis of ADHD. Ten of these were 1 year of age or less; 50 were 2 years old. Psychotropic medications were prescribed for 57%. Psychological services were authorized for 26%; 17% received both. The youngest child medicated with psychotropics was 2 years old when the prescription was filled. Twenty-two different psychotropic agents were prescribed. In 60 instances, two or three medications were used simultaneously. Fifty-eight children were treated with two to six medications over 15 months. Methylphenidate and clonidine were the most commonly used medications, singly or in combination. Such results are likely to be representative of practices outside of Michigan. Researchers at the Massachusetts General Hospital reviewed pharmacotherapy of ADHD across the life cycle.39They found only five controlled studies of methylphenidate in preschool-aged children encompassing only 144 children. These studies reported a variable response, with improvement noted in structured tasks as well as mother-child interactions. Four of the five studies recorded a moderate to robust response; one reported a mixed response. Two of four
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studies regarding tricyclic antidepressants indicated a robust response in preschool-aged children and two reported a moderate response. They found no studies of effects of non-tricyclic antidepressants on ADHD in preschool-aged children. The studies of antipsychotic drugs are too dated and too flawed to draw useful conclusions. The results of studies on both the efficacy and side effects of methylphenidate in preschool-aged children are mixed and inconsistent. Cohen et all4 concluded that psychostimulant drugs appear to be of less certain benefit in the treatment of preschool-aged hyperactive children than with their school-aged counterparts. In contrast, Mayes et alz7found that preschool-aged children with ADHD actually had a better response to methylphenidate than school-aged children. Furthermore, they found that there was no higher frequency of side effects as a function of lower age. Results from Firestone et all9 indicated that methylphenidate has a low toxicity in preschool-aged children but the rate of short-term side effects, mostly mild, is higher in this age group. Some side effects were associated with improvements in behavior. In an older study by Schleifer et a1,38most mothers of preschool-aged children opted not to continue with medication because of disturbing side effects. Among children ages 4 to 6 with ADHD, Musten et a131found improvements on cognitive tests of attention and impulsivity as well as behaviors assessed by parent rating scales with doses of either 0.3 or 0.5 mg/kg of methylphenidate twice per day. Side effects increased at the higher dosage. Interestingly and importantly for this age group, no changes were obtained with respect to the children’s tendencies to comply with parental requests (often a chief reason children are referred for evaluation in the first place). In an earlier study, however, Barkley? found that preschool-aged children on -a dose of 0.5 mg/kg significantly increased rates of compliance with maternal commands. There has been renewed interest in clonidine (an a,-noradrenergic agonist) in recent years for treatment of behavior problems, including ADHD. It is often considered when an alternative to stimulants is necessary or in cases of overaroused, explosive-type symptoms. The few studies that have included children as young as 3 years of age have reported consistently positive responses (less on cognition than behavior) with doses in the 0.025 to 0.16 mg range. Sedation, potential hypotension (rebound hypertension if discontinued precipitously), and small pill size are the main problems with clonidine. One study of a similarly acting type of drug, guanfacine (Tenex) also showed a positive response in children from age 4.39 The minimal information that exists suggests that stimulants, specifically methylphenidate, and clonidine are useful and generally safe if prescribed and monitored appropriately in children as young as 3 years old (Table 1).However, there are insufficient data to draw conclusions about the safety of these drugs in children younger than 3 years of age or about the safety and efficacy of other psychotropic agents, such as buspirone, risperidone, or selective serotonin reuptake inhibitors in preschool-aged children with ADHD. There may be a place for these medications when comorbid conditions exist for which they are specifically indicated. However, until primary care physicians gain more expertise and experience with these newer drugs, it may be wisest to refer children to a child psychiatrist, neurologist, or developmental pediatrician for complicated medication management. Double-blinded, placebo-controlled trials of stimulant medication may be particularly useful for preschool-aged children in determining and demonstrating risk versus benefit. Although somewhat cumbersome and time consuming to organize, this approach has been shown to work well for older children in
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ATTENTION DEFICIT HYPERACTIVITY DISORDER IN PRESCHOOLERS
Table 1. STIMULANTS AND CLONlDlNE FOR PRESCHOOL CHILDREN WITH ADHD Starting Drug
Dose
methylphenidate
2.5 mg
AM
dextroamphetamine
2.5 mg
AM
clonidine
0.025-0.05 mg hs
Increase Dose by 2.5 mg if needed in 3-5 days; then 2 or 3 times a day 2.5 mg if needed in 3-5 days; then 2 or 3 times a day twice daily in 5-7 days; three times daily in 5-7 days; then slowly by 0.025-0.05 mg/d to max of 0.1 mg/dose*
Onset of Action
Duration of Action
15-30 min
2-4 h
15-30 min
3-6 h
1-2 wk
N/A
hs = bedtime. 'Titrate slowly to minimize somnolence. Monitor blood pressure and heart rate initially and with each increased dose. To discontinue, wean over 1 week to avoid rebound hypertension. A transdermal clonidine patch is available for daily doses of 0.1, 0.2, or 0.3 mg/d and lasts 7 days.
identifying true responders to medication (at least in older children) and may provide support for either recommending or, perhaps more importantly, not recommending medi~ation.'~, 21 SUMMARY
The diagnosis of ADHD in preschool-aged children is difficult. High activity level, impulsivity, and short attention span-to a degree-are age-appropriate characteristics of normal preschool-aged children. However, excessive levels of these characteristics impede successful socialization, optimal learning, and positive parent-child interaction. Environmental stressors, inadequate parenting skills, and other diagnoses such as oppositional defiant, posttraumatic stress, or adjustment disorders can mimic ADHD. Although labeling may be necessary to obtain services, the emphasis should be placed on symptom resolution, given the uncertainties of diagnostic accuracy in this age group. Deferring a specific diagnosis of ADHD until confounding issues are clarified should be considered. The evaluation of serious behavior problems in young children must include a comprehensive consideration of environmental, health, cognitive, educational, and behavioral interactions. Both assessment and intervention should focus on the interactions between the child and his or her environment to determine how they facilitate or hinder adaptive integration as both the child and surroundings change and evolve. Treatment invariably necessitates involvement of a child and family psychotherapist or counselor to address behavior management strategies as well as family dynamics, parental psychopathology, or life stress. Parents must understand that counseling is an essential component of treatment and that they must be active participants. Psychopharmacologic intervention may be appropriate in some instances, although conventional wisdom suggests caution in young children, given the limited information about safety and efficacy of many agents, especially in
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children younger than 3 years old. Stimulants appear to be safe in older preschool-aged children. Children started on medication should be monitored closely for both positive and negative effects. A double-blinded, placebo-controlled trial of medication is warranted in equivocal situations.*
References 1. Achenbach TM: Child Behavior Checklist: Cross-Informant Version. Burliigton, VT, Thomas Achenbach, 1991 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, ed 4. Washington, DC, American Psychiatric Association, 1994 3. Barkley RA: The effects of methylphenidate on the interactions of preschool ADHD children with their mothers. J Am Acad Child Adolesc Psychiatry 27336, 1988 4. Barkley RA: Taking Charge of ADHD: The Complete, Authoritative Guide for Parents. New York, Guilford Press, 1995 5. Barkley RA: Defiant Children: A Clinician’s Manual for Assessment and Parent Training. New York, Guilford Press, 1997 6. Beitchman JH, Wekerle C, Hood J: Diagnostic continuity from preschool to middle childhood. J Am Acad Child Adolesc Psychiatry 26:694, 1987 7. Blackman JA, Levine M D A follow-up study of preschool children evaluated for developmental and behavioral problems. Clin Pediatr 26:248, 1987 8. Blackman JA, Westervelt VD, Stevenson R, et al: Management of preschool children with attention deficit-hyperactivity disorder. Topics in Early Childhood Special Education 11:91, 1991 9. Briesmeister JM, Schaefer CE: Handbook of Parent Training: Parents a$ Co-Therapists for Children’s Behavior Problems. New York, John Wiley & Sons, 1997 10. Campbell SB Behavior problems in preschool children: A review of recent research. J Child Psychol Psychiatry 36:113, 1995 11. Campbell SB, Ewing LJ: Hard-to-manage preschoolers: Adjustment at age nine and predictors of continuing symptoms. J Child Psychol Psychiatry 31:871, 1990 12. Campbell SB, Ewing LJ, Breaux AM, et al: Parent-identified behavior problem toddlers: Follow-up at school entry. J Child Psychol Psychiatry 37:473, 1996 13. Campbell SB, Pierce EW, March CL, et al: Hard-to-manage preschool boys: Symptomatic behavior across contexts and time. Child Dev 655336, 1994 14. Cohen NJ, Sullivan J, Minde K, et al: Evaluation of the relative effectiveness of methylphenidate and cognitive behavior modification in the treatment of kindergartenaged hyperactive children. J Abnorm Child Psychol 9:43, 1981 15. Coleman WL, Howard BJ: Family-focused behavioral pediatrics: Clinical techniques for primary care. Pediatr Rev 16:448, 1995 16. Conners C K Conners Parent and Teacher Rating Scales. North Tonawanda, NY, MultiHealth Systems, 1989 17. DiTraglia J: Methylphenidate protocol: Feasibility in a pediatric practice. Clin Pediatr 30:656, 1991 18. Egeland B, Kalkoske M, Gottesman N, et al: Preschool behavior problems: Stability and factors accounting for change. J Child Psychol Psychiatry 31:891, 1990 19. Firestone P, Musten LM, Pisterman S, et al: Short-term side effects of stimulant medication are increased in preschool children with attention-deficit/hyperactivity disorder; A double-blind placebo-controlled study. Journal of Child and Adolescent Pschopharmacology 8:13, 1998 “Personal computer software, developed with support from the US Department of Education, National Institute on Disability and Rehabilitation Research (Award # H133G50148), to facilitate the conduct of a double-blinded, placebo-controlled individual trial of stimulant medication in a primary care practice or clinic is available from the author at the following address: Kluge Children’s Rehabilitation Center, University of Virginia, 2270 Ivy Road, Charlottesville, VA 22901, USA. E-mail: [email protected].
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20. Ingersoll B: Your Hyperactive Child: A Parent’s Guide to Coping with Attention Deficit Disorder. New York, Main Street Books, 1988 21. Kamien M The use of an N-of-1 randomized clinical trial in resolving therapeutic doubt: The case of a patient with an attention disorder. Aust Fam Physician 27(suppl):103, 1998 22. Kaplan BJ, McNicol J, Conte RA, et al: Physical signs and symptoms in preschool-age hyperactive and normal children. Developmental and Behavioral Pediatrics 8:305, 1987 23. Kaplan BJ, McNicol J, Conte RA, et al: Sleep disturbance in preschool-aged hyperactive and nonhyperactive children. Pediatrics 80:839, 1987 24. Lemer JA, Inui TS, Trupin EW, et al: Preschool behavior can predict future psychiatric disorders. J Am Acad Child Adolesc Psychiatry 2442, 1985 25. Levine MD. Pediatric Assessment System. Cambridge, MA, Educators Publishing Service, 1988 26. Levine MD: ANSER System. Cambridge, MA, Educators Publishing Service, 1996 27. Mayes SD, Crites DL, Bixler EO, et al: Methylphenidate and ADHD Influence of age, IQ, and neurodevelopmental status. Dev Med Child Neurol 36:1099, 1994 28. McGee R, Partridge F, Williams S, et al: A twelve-year follow-up of preschool hyperactive children. J Am Acad Child Adolesc Psychiatry 30224, 1991 29. McGee R, Williams S, Feehan M: Attention deficit disorder and age of onset of problem behaviors. J Abnorm Child Psychol 20:487, 1992 30. Meisels S, Marsden D, Wiske MS, et a1 Early Screening Inventory, Revised. Ann Arbor, MI, Rebus, 1997 31. Musten LM, Firestone P, Pisterman S, et al: Effects of methylphenidate on preschool children with ADHD. Cognitive and behavioral functions. J Am Acad Child Adolesc Psychiatry 36:1407, 1997 32. Oberklaid F, Dworkin PH, Levine MDf Developmental-behavioral dysfunction in preschool children: Descriptive analysis of a pediatric consultative model. Am J Dis Child 133:1126, 1979 33. Palfrey JS, Levine MD, Walker DK, et al: The emergence of attention deficits in early childhood: A prospective study. Developmental and Behavioral Pediatrics 6339, 1985 34. Pisterman S, McGrath P, Firestone P, et a1 Outcome of parent-mediated treatment of preschoolers with attention deficit disorder with hyperactivity. J Consult Clin Psychol 57:628, 1989 35. Rappley MD, Mullan PB, Gardiner JC, et al: Attention deficit hyperactivity disorder and the use of psychotropic medication in very young children. Arch Pediatr Adolesc Med, in press 36. Reeves JC, Werry JS, Elkind GS, et al: Attention deficit, conduct, oppositional, and anxiety disorders in children: 11. Clinical characteristics. J Am Acad Child Adolesc Psychiatry 26:144,1987 37. Rosenberg MS, Wilson RJ, Legenhausen E: The assessment of hyperactivity in preschool populations: A multidisciplinary perspective. Topics in Early Childhood Special Education 990, 1989 38. Schleifer M, Weiss G, Cohen N, et al: Hyperactivity in preschoolers and the effect of methylphenidate. Am J Orthopsychiatry 45:38, 1975 39. Spencer T, Biederman J, Wilens T, et al: Pharmacotherapy of attention-deficit hyperactivity disorder across the life cycle. J Am Acad Child Adolesc Psychiatry 35:409, 1996 40. Stormont-Spurgin M, Zentall SS: Contributing factors in the manifestation of aggression in preschoolers with hyperactivity. J Child Psychol Psychiatry 36:491, 1995 41. Strayhom JM, Weidman C S Reduction of attention deficit and internalizing symptoms in preschoolers through parent-child interaction training. J Am Acad Child Adolesc Psychiatry 28:888, 1989
Address reprint requests to James A. Blackman, MD, MPH Kluge Children’s Rehabilitation Center 2270 Ivy Road Charlottesville, VA 22903