New Guidelines: Diagnose Kids for ADHD at Age 4

American Academy of Pediatrics Expands Age Range for Diagnosis of Attention Deficit Hyperactivity Disorder

Medically Reviewed by Laura J. Martin, MD on October 17, 2011
From the WebMD Archives

Oct. 17, 2011 -- Attention deficit hyperactivity disorder (ADHD) should be diagnosed and treated in children as young as age 4, according to new guidelines from the American Academy of Pediatrics.

Previous guidelines for pediatricians, issued 10 years ago, had limited the diagnosis and treatment of ADHD to children aged 6 to 12. The new guidelines expand that age range to include preschoolers and teenagers.

The new guidelines were released at the annual meeting of the American Academy of Pediatrics in Boston. They are also published in the November issue of Pediatrics.

Currently, it's estimated that about 8% of children have ADHD.

The new recommendations say treatment for preschoolers should start with behavioral therapies geared toward teaching parents how to better control problem behaviors.

If a child doesn't improve, then the guidelines recommend escalating to medication with methylphenidate (Concerta, Metadate, Methylin, Ritalin).

"We're not recommending that you just put 4-year-olds on meds right away," says Karen Pierce, MD, a child psychiatrist who helped develop the guidelines. Pierce is also a clinical associate professor of medicine at Northwestern University's Feinberg School of Medicine in Chicago.

"The kids that I put on meds, the preschoolers, have been kicked out of three or four preschools. They've had broken legs or broken arms. I have a 4-year-old who just choked his 2-year-old brother so severely because he was impulsive. Those are the kinds of kids we're talking about," Pierce says.

Evidence for Medicating Preschoolers

The committee's recommendation to use Ritalin to treat young children is in part based on the results of a study of 165 young children who were assigned to take Ritalin or a placebo. In that study, about 21% of kids on the best dose of the medication, and 13% of the kids taking the placebo, achieved remission of their ADHD symptoms.

Researchers said that overall, they found "strong positive effects" in about half the preschoolers who took Ritalin. Those improvements were generally not as large as the benefits seen in older kids who take that drug.

Mark L. Wolraich, MD, chairman of the committee that developed the guidelines, says he doesn't think the new guidelines will encourage more prescribing of medications. Instead, he says, the update and evidence-based recommendations are important because so many primary care doctors are already treating ADHD without much guidance about what works.

Wolraich is a professor of pediatrics and director of the child study center at the University of Oklahoma College of Medicine, in Oklahoma City. "It's clear from the studies that looked at medication use that there are a number of children that are being treated," Wolraich says. "We wanted to make sure that primary care physicians, if they were going to be evaluating children, were using the best evidence for both evaluation and recommendations for treatment."

Experts who were not involved in developing the guidelines agree.

"I think it's definitely a good thing," says Andrew Adesman, MD, chief of developmental and behavioral pediatrics at Steven and Alexandra Cohen Children's Medical Center of New York in New Hyde Park. "Parents have been turning to pediatricians for guidance around behavior and attention concerns, not just in ages 6 to 12 but in preschool and adolescence."

"The American Academy of Pediatrics does identify a place for medication for preschool children, but it should be limited to children with moderate to severe symptoms, children who've had symptoms for nine months or longer, and children for whom behavioral therapy is no longer effective," he says.

ADHD in Teens

Previous guidelines stopped at recommending diagnosis or treatment of AHDH in kids older than age 12.

"There used to be a myth that kids grew out of ADHD. And the new evidence shows that's really not true, that kids don't grow out of it," Pierce tells WebMD.

Teens with ADHD may be overlooked because they're less likely than younger children to also be hyperactive.

But Pierce says treatment of ADHD in kids of all ages is vital because it causes a significant amount of suffering.

Kids with ADHD often have low self-esteem and turn into poor students. Risky and impulsive behavior makes them a danger to themselves. They are often dismissed by their peers and have trouble making friends.

"All of those kinds of things are things we try to prevent because those are the building blocks of adulthood, how you feel as a kid," she says.

Show Sources


American Academy of Pediatrics, Subcommittee on Attention-Deficit/Hyperactivity Disorder, Pediatrics, November 2011.

Karen Pierce, MD, child psychiatrist; clinical associate professor of medicine, Northwestern University's Feinberg School of Medicine, Chicago.

Mark L. Wolraich, MD, professor of pediatrics; director, child study center, University of Oklahoma College of Medicine, Oklahoma City.

Andrew Adesman, MD, chief of developmental and behavioral pediatrics, Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park.

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