Consider ADHD starting at age four: doctor group

NEW YORK Mon Oct 17, 2011 10:43am IST

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NEW YORK (Reuters Health) - The American Academy of Pediatrics this weekend expanded its guidelines for diagnosing and treating kids with attention-deficit hyperactivity disorder, recommending that doctors evaluate all patients age four to 18 that show signs of the condition.

The new guidelines update decade-old recommendations that focused on diagnosing and managing ADHD in kids age six to 12. But behavior problems, overactivity and trouble paying attention can show up earlier, researchers said, and ADHD often persists into adolescence or even adulthood.

Pediatricians should also look out for learning disabilities, anxiety and other issues that can go hand-in-hand with ADHD. And, they should tailor treatment with behavior therapy and medication based on kids' age and severity of symptoms, says a statement published in Pediatrics.

According to data from the Centers for Disease Control and Prevention, between six and nine percent of kids and teens have ADHD, with rates higher in adolescents than younger kids.

"I'm glad to see the guidelines now recognize ADHD can occur both in younger children and older adolescents as well," said Aude Henin, from Massachusetts General Hospital's Child Cognitive-Behavioral Therapy Program. "I think those are things that have been ignored in the past."

Drafted by a 14-member committee, the new recommendations say pediatricians should consult with parents, teachers and other adults in the community about kids' behavior or school-related problems to help them make an accurate diagnosis -- because affected children may not always show symptoms in the doctor's office.

If kids are diagnosed with ADHD, those adults will also play an important role in treatment strategies, especially in young kids.

To treat four- and five-year olds, the authors recommend that parents are trained in techniques to help manage kids' behavior, including positive reinforcement and ignoring or punishing certain behaviors, when necessary. Only when that doesn't work, and moderate or severe ADHD persists, should young kids be put on medication.

J. Russell Ramsay, who studies ADHD at the University of Pennsylvania's Perelman School of Medicine, said that many young kids are overactive or have trouble focusing at times, but that for ADHD to be diagnosed, that behavior must "cause life impairments" in multiple environments -- at home, at school and in relationships with peers.

"The diagnosis is a process," he told Reuters Health. "There may be symptoms that are screened for in the preschool population, but (ADHD) should be tracked over time and reassessed to see if it is persisting."

In school-aged kids, teachers or parents can give kids behavior therapy using similar strategies as in preschoolers. Some may need special education plans, including less homework if it takes them a long time to complete, Ramsay said.

Stimulant medications such as Vyvanse, Ritalin and Concerta have also been shown to be effective alone or alongside therapy in this age group.

Those drugs may have side effects, the report notes, including appetite loss, sleep problems and stomach pain. Youngsters with some signs of ADHD, but not a full diagnosis, shouldn't be medicated.

Some of the guideline authors report consulting for companies that sell ADHD medications in the paper's conflict of interest section.

"Medication certainly has a stronger effect on the core behavior symptoms of ADHD, but it's a matter of what the family's preference is (and) what services are available for them," said Dr. Mark Wolraich of the University of Oklahoma Health Sciences Center, the guidelines' lead author.

"Where at all possible for school-aged kids and adolescents, trying to implement both (medication and therapy) is probably going to be most effective."

Medication and individual behavior therapy are recommended for teens with ADHD. The authors emphasize that doctors need to keep their eyes open for any signs of drug or alcohol abuse in this group -- and if those problems exist, they should be a treatment priority.

Ramsay, who was not part of the guidelines committee, added that car accidents, unplanned pregnancy and sexually transmitted infections are all more common in teens with ADHD than without.

"It's something else that needs to be factored into the dialogue," he said.

Finally, because ADHD can persist for so long, the guidelines point out that communication between families, schools and doctors over the long run will be necessary to help manage the condition.

Doctors "need to have an ongoing relationship with the family," Wolraich told Reuters Health. "The demands and the needs are going to change over time."

SOURCE: bit.ly/jsoh2P Pediatrics, online October 16, 2011.

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