α₂-Adrenergic Agonists or Stimulants for Preschool-Age Children With Attention-Deficit/Hyperactivity Disorder

Abstract

IMPORTANCE Attention-deficit/hyperactivity disorder (ADHD) is diagnosed in approximately 2.4% of preschool-age children. Stimulants are recommended as first-line medication treatment. However, up to 25% of preschool-age children with ADHD are treated with α 2 -adrenergic agonist medications, despite minimal evidence about their efficacy or adverse effects in this age range.OBJECTIVE To determine the frequency of reported improvement in ADHD symptoms and adverse effects associated with α 2 -adrenergic agonists and stimulant medication for initial ADHD medication treatment in preschool-age children. DESIGN, SETTING, AND PARTICIPANTSRetrospective electronic health record review. Data were obtained from health records of children seen at 7 outpatient developmental-behavioral pediatric practices in the Developmental Behavioral Pediatrics Research Network in the US. Data were abstracted for 497 consecutive children who were younger than 72 months when treatment with an α 2 -adrenergic agonist or stimulant medication was initiated by a developmental-behavioral pediatrician for ADHD and were treated between

Comparison of Medication Treatments for Preschool Children With ADHD

“…11 This near absence of published data is particularly striking given recent large studies (N = 12 639 and N = 955) of preschool-age children with ADHD, disruptive behavior disorders, or both that showed α 2 -adrenergic agonist use has exceeded methylphenidate use in some populations. 10,12 To address this critical gap in the literature and begin constructing an evidence base to guide medication treatment of preschool ADHD, Harstad et al 13 conducted the first study to determine and compare the frequency of reported improvement in ADHD symptoms and adverse effects with α 2 -adrenergic agonist and stimulant medication treatment in this age group. In this retrospective study, electronic health records from 7 outpatient developmental-behavioral pediatrics practices were reviewed for 497 children who were younger than 72 months when they initiated ADHD treatment with an α 2 -adrenergic agonist or stimulant medication.…”

“…Several adverse effects were reported at higher rates for stimulants than α 2 -adrenergic agonists, including moodiness/irritability (50% vs 29%), appetite suppression (38% vs 7%), and sleep difficulties (21% vs 11%), while only the adverse effect of daytime sleepiness was more common with α 2 -adrenergic agonists than stimulants (38% vs 3%). Consistent with prior studies, Harstad et al 13 showed an association between younger age and initiation of α 2 -adrenergic agonists rather than stimulants (age at initiation of treatment × medication class interaction P = .006). Although younger preschool-age children were not more likely to have reported clinical improvement with α 2 -adrenergic agonists than stimulants in this study, children younger than 4 years who were prescribed α 2 -adrenergic agonists were likely to continue receiving those medications longer than those prescribed stimulants.…”

“…Despite these limitations, the report by Harstad et al 13 represents an important contribution. This study is the first step toward filling the void in the evidence base regarding com-parative effectiveness of medication treatment for preschoolage children with ADHD.…”

Ways to Address Perinatal Mast Cell Activation and Focal Brain Inflammation, including Response to SARS-CoV-2, in Autism Spectrum Disorder

“…If these are not sufficient, one should consider the beta-blocker propranolol that has good anti-anxiety properties without clouding the mental abilities and has also been reported to improve language in children with ASD [ 297 ]. Alternatively, one may recommend the use of alpha 2-receptor agonists [ 298 ] such as clonidine [ 299 , 300 ] and guanfacine [ 301 , 302 ], usually administered at bedtime especially since clonidine reduces sleep initiation latency and night awakening [ 303 ]. Moreover, caution should be exercised because such adrenergic blocking drugs may cause bradycardia and a drop in blood pressure.…”

Error in Results

“…The Original Investigation titled “α 2 -Adrenergic Agonists or Stimulants for Preschool-Age Children With Attention-Deficit/Hyperactivity Disorder,” published in the May 4, 2021, issue of JAMA , included an error in the Results section that indicated an incorrect number of children who received behavioral therapy before medication initiation. This included indicating that 309, rather than 225, children received behavioral therapy prior to initiation of medication in the Results and Table 1.…”