Diagnosis, Treatment of ADHD in Very Young Children May Be Inappropriate

Diagnosis of ADHD in preschoolers called into question and worries abound that doctors are prescribing stimulant medications for ADHD to preschoolers when the drugs have never been tested on very young children.

Children age three and under are being diagnosed with attention-deficit hyperactivity disorder (ADHD), in the absence of clear guidelines for this age group, and more than half of these children receive psychotropic medication, according to a report published in the October issue of the Archives of Pediatrics and Adolescent Medicine.

Dr. Marsha D. Rappley and colleagues, from Michigan State University in East Lansing, reviewed the medical claims records of 223 children who had been diagnosed with ADHD at or before the age of 3 years. More than one fourth had been diagnosed at or before the age of 2 years. Boys comprised 79.8% of the sample and 68.2% were white.

Comorbid conditions common among older children with ADHD were reported in 44% of the subjects, most commonly language and cognitive development problems. Other medical conditions were reported in 41%. Forty percent of the children were treated for physical injuries over the 15-month study period.

"These little children clearly have multiple problems, both in mental health and in chronic health," Dr. Rappley said in an interview. "I think primary care physicians want to address their urgent needs, but they don't have the information they need."

Psychological treatment was provided for only 27% of the children.

Psychotropic medications were given to 57%, most frequently methylphenidate and/or clonidine. Just over one third of children receiving medication took two or three psychotropic drugs simultaneously, with thirty different combinations of drugs used. Close to half of the children taking medications took from two to six different drugs over time.

Of particular concern, the authors comment, is that "... the extreme variation in the use of psychotropic medications suggests haphazard use at worst and uninformed use at best." They note that most of the drugs used have not been tested for safety and efficacy in very young children, either singly or in combination.

"When we see 22 different medications used in almost more ways than we could count," said Dr. Rappley, "... this reflects that we don't have guidance on how to use these medications and whether these are the best treatments for very young children."

"As professionals, we need to have a way of describing these children and getting appropriate services for them," she added. "Right now, we don't know how to do that."

Sources:

• Archives of Pediatrics and Adolescent Medicine (Arch Pediatr Adolesc Med 1999;153:1039-1045).

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