Preschool ADHD treatment

Introduction Preschool psychopharmacology is nearly entirely off-label [1], and the use of psychopharmacological interventions essentially exposes a young child to agents whose potential risks and benefits may not be entirely known. In addition to potentially unintended central nervous system (CNS) and other adverse effects, children display more rapid hepatic and renal metabolisms which may change the dosing and administration strategy for psychopharmacological intervention in this age group. Few studies examine the effects of psychiatric medications on preschool-aged children, and even fewer offer data on long-term outcomes. The limited support of pharmacotherapy as a safe and efficacious treatment for young children with attention-deficit hyperactivity disorder (ADHD) no doubt provides the rationale for recommending behavioral therapy as the initial intervention for these patients, or at a minimum, as a key part of a comprehensive treatment plan. The lack of US Food and Drug Administration (FDA) approval for many of the ADHD pharmacotherapies for use in the preschool age group, however, does not suggest that available approved medications cannot be used. It does, however, emphasize the importance of a careful and thorough assessment of the young child, and cautious determination of the degree of impairment and the need for treatment. This risk–benefit analysis is a crucial aspect of treatment planning. If pharmacotherapy is ultimately determined to be warranted, the prescribing clinician is obligated to provide a detailed and collaborative informed consent process. Epidemiology One epidemiological study found that 12% of preschool-aged children met criteria for an impairing Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV disorder [2], with 9% meeting criteria for a behavioral disorder. Carter et al. also found that 21.6% of children entering formal schooling (kindergarten or first grade) met criteria for an impairing DSM-IV disorder [3]. In school-age children, ADHD has a 5.7% worldwide prevalence [4–6], while epidemiological surveys of community samples have reported 2–6% of preschoolers meet full criteria for ADHD [7–9]. Symptoms of the disorder are very common in the preschool population. Two studies have reported that 59–86% of 2- to 6-year-olds referred to psychiatric clinics have at least some symptoms of the disorder [9, 10]. A careful assessment by a skilled clinician is necessary to differentiate “true” ADHD from other disorders with overlapping symptoms, or even from “normal” development.