Comparison of Medication Treatments for Preschool Children With ADHD

Abstract

Recognition of attention-deficit/hyperactivity disorder (ADHD) in the preschool age group is on the rise, with an increase in preschool ADHD rates in US nationally representative samples from 1.0% in 2007 to 2008 to 2.4% in 2016. 1 Having a preschool-age child (ie, 3-5 years) with ADHD is associated with numerous negative outcomes in the home (eg, disordered parent-child relationships, elevated family stress 2 ) as well as out-of-home settings (eg, impaired preacademic skills, peer interaction difficulties, 2 expulsion from preschool and childcare settings 3 ), underscoring the importance of identification and treatment. Guidelines from the American Academy of Pediatrics and the Society for Developmental-Behavioral Pediatrics (SDBP) recommend behavioral interventions as first-line treatment for preschool-age children with ADHD. 4,5 However, behavioral interventions alone do not sufficiently improve ADHD-related symptoms and impairment in a large percentage (>80%) of children. 6 When behavioral treatments are inadequate, the American Academy of Pediatrics guideline recommends the stimulant methylphenidate as initial pharmacotherapy for preschool-age children with ADHD because it is the medication with the most evidence of efficacy and safety in this age group. 4,6 However, alternative medication options are sometimes needed given the diminished efficacy and higher rates of adverse effects associated with methylphenidate in preschool-age children compared with school-age children. 6,7 For this reason, a guideline by the American Academy of Child and Adolescent Psychiatry's Preschool Psychopharmacology Working Group recommends treatment with α 2 -adrenergic agonists for preschool-age children with ADHD who are unresponsive to or intolerant of treatment with stimulant medication. 8 In addition, based on current treatment patterns 9,10 and expert consensus, the SDBP Complex ADHD guideline recommends α 2 -adrenergic agonists as the initial medication treatment for preschool-age children with ADHD in the specific clinical scenarios of coexisting severe irritability, oppositional behavior, or both, while methylphenidate is recommended first in the absence of this concurrent symptomatology. 5 However, an important caveat to the SDBP recommendation is the lack of prior ADHD medication comparative efficacy trials among preschool-age children. Furthermore, the evidence base is remarkably limited regarding management of ADHD with α 2 -adrenergic agonists in this age group because only 1 small

A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD

“…Despite this stronger methodology among the comorbid ADHD and ASD samples, as was previously mentioned, none of these studies examined the use of CNS stimulants in this population, a critical gap in the literature. Furthermore, there is a particular dearth of data for the capacity of alpha agonists to improve irritability among youth with ADHD, which is surprising given their frequent use for youth with ADHD ( 32 ). The inconsistency in use of a placebo vs. active control also limits our ability to make direct comparisons across these studies.…”

Is ADHD a way of conceptualizing long-term emotional stress and social disadvantage?

“…The remarkably increased use of psychotropic medication can partly be explained by the fact that more and more children receive an ADHD diagnose, and some researchers have warned of a lack of knowledge about the effects on prefrontal cortex of central stimulants in children who are prescribed such medication, especially at an early age ( 4 , 5 ). Consequently, it is important to address that even pre-school children (i.e., 3–5 years of age) are becoming a target of ADHD diagnostics, for example in the USA where there this group is on the rise, from 1.0 % in 2007 and 2008, to 2.4 % in 2016 ( 6 ).…”