Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Sunday, October 16, 2011

Diagnosing ADHD Under Age 6: A Mistaken Idea

Once again ADHD is in the news. At the American Academy of Pediatrics National Conference and Exhibition this weekend in Boston, the new guidelines for diagnosis and treatment of ADHD were unveiled with much fanfare. The most significant change is that the AAP now endorses diagnosing the disorder from age 4-18, a change from the previous guidelines which recommended diagnosis from age 6-12. I take no issue with extending the age of diagnosis upward. But the new recommendation to extend the diagnosis down to age 4 is very worrisome.

As I describe in a previous post, what is now called ADHD is a constellation of symptoms that represent problems of regulation of behavior, attention and emotions. These problems have complex causes. There may be a biological vulnerabilities, which often have a genetic component. Often there are associated sensory processing problems. Family conflict, including parent-child conflict as well as marital conflict, is clearly associated with problems of self regulation. Sleep and eating problems often occur within the context of family conflict and can exacerbate problems of self-regulation.

Children who are struggling in a variety of ways are scheduled in pediatric practices for an "ADHD evaluation." The question asked is: "Do symptoms meet diagnostic criteria?" The more appropriate question should be "What is the experience of this particular child and what can we do to set things in a better direction?" By invoking the label of ADHD, thinking may stop. Curiosity about the meaning of behavior ends. However, years of longitudinal research, as I describe in my book, Keeping Your Child in Mind, has shown that children develop the capacity for empathy, flexible thinking and emotional regulation when parents respond to the meaning of behavior rather than simply the behavior itself.

A press release regarding the new guidelines describes the recommendations for children under 6 as follows.
According to the AAP guidelines, in preschool children (ages 4 and 5) with ADHD, doctors should first try behavioral interventions, such as group or individual parent training in behavior management techniques. Methylphenidate may be considered for preschool children with moderate to severe symptoms who do not see significant improvement after behavior therapy, starting with a lower dose.
Certainly children with problems of self-regulation are struggling, and they absolutely should receive treatment. But receiving a diagnosis of ADHD should not be the only route to receiving treatment, particularly if that treatment consist primarily of "parent training" "behavior management" or medication. There are a whole range of other interventions that can be very helpful to these struggling children and families. These include parent-child psychotherapy and occupational therapy that aim specifically to improve a child's capacity for self-regulation. Getting a label should not be a prerequisite for getting help.

Addressing "comorbidities" does not solve the problem. What this means is simply adding more letters to the child's diagnosis such as ODD (oppositional defiant disorder) CD(conduct disorder) that represent meaningless descriptions of symptoms without any consideration of underlying cause. In my experience, almost all children who have the diagnosis of ADHD are oppositional and defiant. But there are as many variations to the causes of this behavior as there are families.

Under age six children can get the greatest benefit from alternative interventions. This is the time when the brain is most plastic. Changing relationships can change the brain. In addition there are not, or at least should not be, the academic concerns that begin in first grade. Once kids begin to fall behind academically it can affect their self-esteem, and so the pressures to treat with medication increase.

A study done last year showed that kids who are the youngest in their class are 60 percent more likely to be diagnosed with ADHD than kids who are the oldest. There is a wide range of maturity rate. A four or five-year- old who is among the youngest in the class is at particular risk for being diagnosed with ADHD for what is in fact a normal developmental variation.

Recent reports show a dramatic rise in both diagnosis of ADHD and prescribing of stimulant medication for ADHD. We can be sure that with the implementation of these new guidelines, this trend will continue.

4 comments:

  1. A long time ago one ADHD advocate admitted that ADHD could not really be distinguished from the high end of the normal bell-shaped curve for activity level and ability to concentrate (let alone from problems due to all of the essential family and relationship factors you are talking about). He recommended diagnosing ADHD in anyone who was in the top 5% of this curve.

    That's like saying anyone playing in the NBA has acromegaly (an excess of growth hormone) because they are so tall.

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  2. An even worse issue is that Texas Governor, Rick Perry's administration, has changed education law to prevent doctors from prescribing ADD medications such as Ritalin. I have family in Texas that have been told by pharmacists that the ADD medication is no longer being manufactured.

    So we went to Costco while they were here just to show family that Ritalin is available and still manufactured. So as long as Texas says that ritalin isn't available, Texans should know that they can still have their prescription filled, but they have to go to another state.

    The question was raised by TEA (Texas Education Association) and John Breeding, PhD, Director of Texans for Safe Education.

    However, when a School steps in and says they can override a prescription, written by a board-certified doctor, then that's a dangerous precedent.

    Sure, diagnosing before the age of 6 may be a little presumptuous, but considering all the wacky ideas coming out of Texas, it's not surprising.

    As for myself, I was properly diagnosed, had 3 IQ tests, and find that ritalin helps me be successful in life.

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  3. As a practicing child psychiatrist I was interested in the decisions of the AAP. I've treated teenagers for ADHD for years and thought their extending limits of treatment in that direction reasonable but I do find the treatment of younger kids complicated. Younger children seem more prone to side effects even with benefits up until the age of 8 when side effect response seems to lessen. In any event I have heard an accomplished educator say that if classroom size were closer to 10 per class than the current 20 or 20+ perhaps half the kids on stimulants now would not have to take them.

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  4. I think that the point of the board ruling was not so physicians could start handing out pills willy-nilly to any misbehaved child. The point of the earlier evaluation time is simply to enable parents to get their child more options or help earlier.

    Your statement:

    "Getting a label should not be a prerequisite for getting help."

    Unfortunately, in this day and age, that's not necessarily true. I wish it was. Hopefully this ruling will help in that; after all, lowering the evaluation age will open the door for more parents to get the help that they need more quickly, whether that be parenting interventions, behavioral help, etc.

    Also, this statement:

    "Addressing "comorbidities" does not solve the problem. What this means is simply adding more letters to the child's diagnosis such as ODD (oppositional defiant disorder) CD(conduct disorder) that represent meaningless descriptions of symptoms without any consideration of underlying cause."

    I'm sorry, but those "letters" do not represent "meaningless descriptions of symptoms". That is an incredibly arrogant, naive statement that I certainly hope I'm misunderstanding. Are you saying that people diagnosed with these disorders are simply faking it?

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