CME
Treatment strategies for ADHD in preschool and school-age children Maria Sonnack; Anthony Brenneman, MPAS, PA-C
ABSTRACT This review presents current best-evidence treatment options for children with attention-deficit hyperactivity disorder (ADHD), including a review of current literature on the efficacy and safety of psychostimulant medications, particularly methylphenidate, used in treating preschoolers and school-age children with ADHD. Keywords: attention-deficit hyperactivity disorder (ADHD), children, psychostimulants, methylphenidate, growth, behavioral therapy
Maria Sonnack is a student in the PA program at the University of Iowa’s Carver College of Medicine in Iowa City, Iowa. Anthony Brenneman is director of the PA program at the University of Iowa. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000453859.08958.31 Copyright © 2014 American Academy of Physician Assistants
22
www.JAAPA.com
T
he increasing number of children being diagnosed with attention-deficit hyperactivity disorder (ADHD) has been a topic of hot debate among healthcare providers and the community in recent years. Due to shortages of psychiatrists, as well as other factors, many parents rely on their primary care providers to provide ADHD treatment for their children. Because ADHD is within the scope of psychiatry and behavioral medicine, many primary care providers may feel uncomfortable diagnosing and treating it. However, the increased diagnoses of ADHD in children and provider shortage mean that primary care providers, including physician assistants (PAs), must understand current best treatment guidelines for this common childhood psychiatric condition. For clarification, this paper analyzes literature focused on children ages 3-5 years as preschoolers and children ages 6-12 as school-age children.1 Volume 27 • Number 10 • October 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment strategies for ADHD in preschool and school-age children
Key points The increasing number of children being diagnosed with ADHD and a shortage of psychiatrists mean that primary care providers must understand treatment guidelines for ADHD. Primary care providers should evaluate for ADHD in children ages 4 to 18 years who exhibit academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. Children with ADHD often have comorbid psychiatric disorders. Psychostimulant medications are the first-line therapy for ADHD and have been found safe and effective in preschoolers.
EPIDEMIOLOGY According to the CDC, 5.2 million children ages 3 to 17 years (about 8.4%) have ever been diagnosed with ADHD.2 About 12% of boys have ever been diagnosed with ADHD, compared with 4.7% of girls.2 The number of boys diagnosed with ADHD is continually rising, leading community members and healthcare providers to ask if this increase is due to a true presence of ADHD, or whether young, hyperactive, “typical” boys are being incorrectly diagnosed. Scott Lilienfeld and Hal Arkowitz make a good point in their article, Are Doctors Diagnosing Too Many Kids with ADHD, that although the data demonstrate a possible overdiagnosis of ADHD in children, especially in boys, undertreatment of ADHD may be a bigger problem than overtreatment.3 Lilienfeld and Arkowitz are not the only ones to bring this issue to light. Jensen and colleagues also indicate in their article that data exist suggesting that physicians in the community tend to use lower-than-optimal doses in treating ADHD in children.4 Also according to Jensen and colleagues, “providers and parents alike may be sometimes afraid of the medication and too often settle for a less than complete response.”4 Based on this information, providers not only must understand how to properly diagnose ADHD in children and adolescents, but also how to appropriately treat it. DIAGNOSIS According to the American Academy of Pediatrics (AAP), primary care providers should evaluate for ADHD in any child ages 4 through 18 years who has academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.5 The AAP’s clinical practice guideline on ADHD recommends using the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) to make the diagnosis of ADHD.6 This includes documenting impairment in more than one major setting. Information needed to make the diagnosis should come from a mix of reports from parents or guardians, teachers, and other JAAPA Journal of the American Academy of Physician Assistants
Learning objectives Identify treatment strategies for preschool children with ADHD. Identify treatment strategies for school-age children with ADHD. Recognize the risks and benefits of psychostimulant medications for the treatment of ADHD in children.
school and mental health clinicians involved in the child’s care.5 Resources for clinicians, patients, and families can be found at http://www.aap.org. Other diagnoses also need to be ruled out. ADHD is the most commonly diagnosed psychiatric condition in children.4,7 Most children with ADHD also have other psychiatric conditions, including oppositional defiant disorder (54% to 84% of patients), conduct disorder, substance abuse disorders (15% to 19%), mood disorders (33%), coexisting learning or language problems (25% to 35%), and anxiety disorders (up to 33%).8-13 According to the DSM-5, a differential list of the following should be considered in making the diagnosis of ADHD: oppositional defiant disorder, intermittent explosive disorder, other neurodevelopmental disorders, specific learning disorder, intellectual developmental disorder, autism spectrum disorder, reactive attachment disorder, anxiety disorders, depressive disorders, bipolar disorder, disruptive mood dysregulation disorder, substance abuse disorders, personality disorders, psychotic disorders, medication-induced symptoms of ADHD, and neurocognitive disorders.6 Current evidence suggests that the main cause of ADHD is genetic.14 TREATMENT The use of psychostimulant medications such as methylphenidate in preschoolers is a topic of concern for providers and parents. Although the DSM-5 does not cite developmentally adjusted ADHD criteria for diagnosis of the disorder in preschoolers, current surveys report that 2% to 6% of preschoolers meet full criteria for ADHD.15-17 According to Greenhill and colleagues, due to the lack of appropriate criteria for diagnosis of ADHD in preschoolers, efforts among the psychiatric community have focused on redefining the current diagnostic criteria, such as the Preschool Age Psychiatric Assessment (PAPA), for children in this age group.18 Because of the large prevalence of behavioral problems and associated comorbidities within this age group, criteria must be redefined to avoid overdiagnosis and to assure proper identification and treatment of those who need it. Preschoolers with ADHD are more frequently suspended from preschool and/or daycare due to disruptive behavior, more frequently suffer from academic impairment, and are more frequently placed in special education programs than same-aged controls.19-21 Preschoolers with www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
23
CME
ADHD also have an increased incidence of comorbidities, as well as increased rates of developmental delays, language problems, and high rates of underachievement in reading and math.20,22,23 For this reason, clinicians must appropriately diagnose and effectively treat ADHD in this age group. The American Academy of Child and Adolescent Psychiatry (AACAP) recently released updated recommendations for assessing and treating children and adolescents with ADHD (Table 1). Because these recommendations do not specifically cover preschoolers, we will present current best evidence for treatment of ADHD in this age group. Interventions accepted for the treatment of ADHD in preschoolers are parent behavior training, psychopharmacologic medications (including psychostimulant and nonstimulant medication), and community care. Psychostimulants have long been the gold standard of treatment of ADHD in children and adolescents. However, because very little research has been done to examine the implications of these drugs in the preschoolers, the FDA does not recommend their use as first-line therapy in children under age 6 years. Based on a review of current literature, parent behavior training has been suggested as first-line therapy for treatment of ADHD in at-risk preschoolers.4,7,24 Doses for psychostimulants to treat ADHD should be titrated according to patient response to the medication, and not to a specific goal dose or specific dose for weight. Start low, and titrate up slowly until a therapeutic response has been achieved. TABLE 1.
AACAP recommendations in the assessment and treatment of children and adolescents with ADHD1
• Recommendation 1: Screening for ADHD should be part of every patient’s mental health assessment. • Recommendation 2: Evaluation of the preschooler, child, or adolescent for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patient’s school or daycare functioning, evaluation for comorbid psychiatric disorders, and review of the patient’s medical, social, and family histories. • Recommendation 3: If the patient’s medical history is unremarkable, laboratory or neurologic testing is not indicated. • Recommendation 4: Psychologic and neuropsychologic tests are not mandatory for the diagnosis of ADHD, but should be performed if the patient’s history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient’s intellectual ability. • Recommendation 5: Evaluate the patient with ADHD for comorbid psychiatric disorders. • Recommendation 6: Develop a well-thought-out and comprehensive plan for the patient with ADHD. • Recommendation 7: The initial psychopharmacologic treatment of ADHD should be a trial with an FDA-approved agent for treating ADHD. 24
Parent behavior training teaches parents how to best manage problem behaviors in their children, with a focus on effective discipline strategies that use rewards and nonpunitive consequences, and promote a healthy, positive relationship between parent and child.7 Commonly used programs include the Positive Parenting Program, Incredible Years Parenting Program, Parent-Child Interaction Therapy, and the New Forest Parenting Program.7 Parent behavior training programs have been shown to reduce disruptive behaviors in preschoolers, including ADHD behavioral symptoms, as well as increase confidence in parenting skills among parents of these children.7 A significant reason for failure of these programs is lack of adherence to completion of the recommended number of sessions.7 Several sources recommend psychostimulants, such as methylphenidate, as second-line treatment of ADHD in preschoolers.5,7,18,24,25 The Preschool ADHD Treatment Study (PATS) is being used widely as current best evidence on the efficacy and safety of these drugs in preschoolers. PATS demonstrated that treatment with methylphenidate significantly reduced ADHD symptom scores compared to placebo (P
Treatment strategies for ADHD in preschool and school-age children Maria Sonnack; Anthony Brenneman, MPAS, PA-C
ABSTRACT This review presents current best-evidence treatment options for children with attention-deficit hyperactivity disorder (ADHD), including a review of current literature on the efficacy and safety of psychostimulant medications, particularly methylphenidate, used in treating preschoolers and school-age children with ADHD. Keywords: attention-deficit hyperactivity disorder (ADHD), children, psychostimulants, methylphenidate, growth, behavioral therapy
Maria Sonnack is a student in the PA program at the University of Iowa’s Carver College of Medicine in Iowa City, Iowa. Anthony Brenneman is director of the PA program at the University of Iowa. The authors have disclosed no potential conflicts of interest, financial or otherwise. DOI: 10.1097/01.JAA.0000453859.08958.31 Copyright © 2014 American Academy of Physician Assistants
22
www.JAAPA.com
T
he increasing number of children being diagnosed with attention-deficit hyperactivity disorder (ADHD) has been a topic of hot debate among healthcare providers and the community in recent years. Due to shortages of psychiatrists, as well as other factors, many parents rely on their primary care providers to provide ADHD treatment for their children. Because ADHD is within the scope of psychiatry and behavioral medicine, many primary care providers may feel uncomfortable diagnosing and treating it. However, the increased diagnoses of ADHD in children and provider shortage mean that primary care providers, including physician assistants (PAs), must understand current best treatment guidelines for this common childhood psychiatric condition. For clarification, this paper analyzes literature focused on children ages 3-5 years as preschoolers and children ages 6-12 as school-age children.1 Volume 27 • Number 10 • October 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Treatment strategies for ADHD in preschool and school-age children
Key points The increasing number of children being diagnosed with ADHD and a shortage of psychiatrists mean that primary care providers must understand treatment guidelines for ADHD. Primary care providers should evaluate for ADHD in children ages 4 to 18 years who exhibit academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity. Children with ADHD often have comorbid psychiatric disorders. Psychostimulant medications are the first-line therapy for ADHD and have been found safe and effective in preschoolers.
EPIDEMIOLOGY According to the CDC, 5.2 million children ages 3 to 17 years (about 8.4%) have ever been diagnosed with ADHD.2 About 12% of boys have ever been diagnosed with ADHD, compared with 4.7% of girls.2 The number of boys diagnosed with ADHD is continually rising, leading community members and healthcare providers to ask if this increase is due to a true presence of ADHD, or whether young, hyperactive, “typical” boys are being incorrectly diagnosed. Scott Lilienfeld and Hal Arkowitz make a good point in their article, Are Doctors Diagnosing Too Many Kids with ADHD, that although the data demonstrate a possible overdiagnosis of ADHD in children, especially in boys, undertreatment of ADHD may be a bigger problem than overtreatment.3 Lilienfeld and Arkowitz are not the only ones to bring this issue to light. Jensen and colleagues also indicate in their article that data exist suggesting that physicians in the community tend to use lower-than-optimal doses in treating ADHD in children.4 Also according to Jensen and colleagues, “providers and parents alike may be sometimes afraid of the medication and too often settle for a less than complete response.”4 Based on this information, providers not only must understand how to properly diagnose ADHD in children and adolescents, but also how to appropriately treat it. DIAGNOSIS According to the American Academy of Pediatrics (AAP), primary care providers should evaluate for ADHD in any child ages 4 through 18 years who has academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity.5 The AAP’s clinical practice guideline on ADHD recommends using the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) to make the diagnosis of ADHD.6 This includes documenting impairment in more than one major setting. Information needed to make the diagnosis should come from a mix of reports from parents or guardians, teachers, and other JAAPA Journal of the American Academy of Physician Assistants
Learning objectives Identify treatment strategies for preschool children with ADHD. Identify treatment strategies for school-age children with ADHD. Recognize the risks and benefits of psychostimulant medications for the treatment of ADHD in children.
school and mental health clinicians involved in the child’s care.5 Resources for clinicians, patients, and families can be found at http://www.aap.org. Other diagnoses also need to be ruled out. ADHD is the most commonly diagnosed psychiatric condition in children.4,7 Most children with ADHD also have other psychiatric conditions, including oppositional defiant disorder (54% to 84% of patients), conduct disorder, substance abuse disorders (15% to 19%), mood disorders (33%), coexisting learning or language problems (25% to 35%), and anxiety disorders (up to 33%).8-13 According to the DSM-5, a differential list of the following should be considered in making the diagnosis of ADHD: oppositional defiant disorder, intermittent explosive disorder, other neurodevelopmental disorders, specific learning disorder, intellectual developmental disorder, autism spectrum disorder, reactive attachment disorder, anxiety disorders, depressive disorders, bipolar disorder, disruptive mood dysregulation disorder, substance abuse disorders, personality disorders, psychotic disorders, medication-induced symptoms of ADHD, and neurocognitive disorders.6 Current evidence suggests that the main cause of ADHD is genetic.14 TREATMENT The use of psychostimulant medications such as methylphenidate in preschoolers is a topic of concern for providers and parents. Although the DSM-5 does not cite developmentally adjusted ADHD criteria for diagnosis of the disorder in preschoolers, current surveys report that 2% to 6% of preschoolers meet full criteria for ADHD.15-17 According to Greenhill and colleagues, due to the lack of appropriate criteria for diagnosis of ADHD in preschoolers, efforts among the psychiatric community have focused on redefining the current diagnostic criteria, such as the Preschool Age Psychiatric Assessment (PAPA), for children in this age group.18 Because of the large prevalence of behavioral problems and associated comorbidities within this age group, criteria must be redefined to avoid overdiagnosis and to assure proper identification and treatment of those who need it. Preschoolers with ADHD are more frequently suspended from preschool and/or daycare due to disruptive behavior, more frequently suffer from academic impairment, and are more frequently placed in special education programs than same-aged controls.19-21 Preschoolers with www.JAAPA.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
23
CME
ADHD also have an increased incidence of comorbidities, as well as increased rates of developmental delays, language problems, and high rates of underachievement in reading and math.20,22,23 For this reason, clinicians must appropriately diagnose and effectively treat ADHD in this age group. The American Academy of Child and Adolescent Psychiatry (AACAP) recently released updated recommendations for assessing and treating children and adolescents with ADHD (Table 1). Because these recommendations do not specifically cover preschoolers, we will present current best evidence for treatment of ADHD in this age group. Interventions accepted for the treatment of ADHD in preschoolers are parent behavior training, psychopharmacologic medications (including psychostimulant and nonstimulant medication), and community care. Psychostimulants have long been the gold standard of treatment of ADHD in children and adolescents. However, because very little research has been done to examine the implications of these drugs in the preschoolers, the FDA does not recommend their use as first-line therapy in children under age 6 years. Based on a review of current literature, parent behavior training has been suggested as first-line therapy for treatment of ADHD in at-risk preschoolers.4,7,24 Doses for psychostimulants to treat ADHD should be titrated according to patient response to the medication, and not to a specific goal dose or specific dose for weight. Start low, and titrate up slowly until a therapeutic response has been achieved. TABLE 1.
AACAP recommendations in the assessment and treatment of children and adolescents with ADHD1
• Recommendation 1: Screening for ADHD should be part of every patient’s mental health assessment. • Recommendation 2: Evaluation of the preschooler, child, or adolescent for ADHD should consist of clinical interviews with the parent and patient, obtaining information about the patient’s school or daycare functioning, evaluation for comorbid psychiatric disorders, and review of the patient’s medical, social, and family histories. • Recommendation 3: If the patient’s medical history is unremarkable, laboratory or neurologic testing is not indicated. • Recommendation 4: Psychologic and neuropsychologic tests are not mandatory for the diagnosis of ADHD, but should be performed if the patient’s history suggests low general cognitive ability or low achievement in language or mathematics relative to the patient’s intellectual ability. • Recommendation 5: Evaluate the patient with ADHD for comorbid psychiatric disorders. • Recommendation 6: Develop a well-thought-out and comprehensive plan for the patient with ADHD. • Recommendation 7: The initial psychopharmacologic treatment of ADHD should be a trial with an FDA-approved agent for treating ADHD. 24
Parent behavior training teaches parents how to best manage problem behaviors in their children, with a focus on effective discipline strategies that use rewards and nonpunitive consequences, and promote a healthy, positive relationship between parent and child.7 Commonly used programs include the Positive Parenting Program, Incredible Years Parenting Program, Parent-Child Interaction Therapy, and the New Forest Parenting Program.7 Parent behavior training programs have been shown to reduce disruptive behaviors in preschoolers, including ADHD behavioral symptoms, as well as increase confidence in parenting skills among parents of these children.7 A significant reason for failure of these programs is lack of adherence to completion of the recommended number of sessions.7 Several sources recommend psychostimulants, such as methylphenidate, as second-line treatment of ADHD in preschoolers.5,7,18,24,25 The Preschool ADHD Treatment Study (PATS) is being used widely as current best evidence on the efficacy and safety of these drugs in preschoolers. PATS demonstrated that treatment with methylphenidate significantly reduced ADHD symptom scores compared to placebo (P
