Can Guidelines Help Reduce the Medicalization of Early Childhood?

Abstract

See related article, p 1423The 2011 publication of the American Academy of Pediatrics' (AAP) clinical practice guidelines for the diagnosis, evaluation, and treatment of attention-deficit hyperactivity disorder (ADHD) in children and adolescents emphasized special circumstances and concerns in specific age groups.1Management Steering Committee on Quality Improvement and Subcommittee on Attention-Deficit/Hyperactivity DisorderADHD: Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents.Pediatrics. 2011; 128 (Epub October 16, 2011): 1007-1022Crossref PubMed Scopus (1276) Google Scholar In particular, the guidelines provided new recommendations to include preschool-aged children—expanding the lower age range from 6 years of age to 4 years of age. In the diagnosis and treatment of ADHD, the guidelines considered confounding factors such as value judgments, parental preferences, and benefit-harm assessments while acknowledging that specific cultural differences were beyond the scope of the guidelines. In young children with concerning ADHD behaviors, clear emphasis was placed on the importance of parent training programs that “must include helping parents develop age-appropriate developmental expectations and specific management skills for problem behaviors.” For preschool children ages 4 and 5, the action statement stressed “the primary care clinician should prescribe parent and/or teacher-administered behavior therapy as the first line of treatment (quality of evidence A/strong recommendation).” See related article, p 1423 Leading up to these 2011 clinical practice guidelines, the AAP Subcommittee on ADHD must have recognized many growing concerns about the diagnosis of ADHD in preschool children. In this issue of The Journal, evidence for such concern has become apparent. Visser et al examine the 2009-2010 Children with Special Health Care Needs national parental-reported survey data estimating the geographic prevalence of ADHD and the general pattern of its behavioral and pharmacologic treatments (alone or in combination) by state, age, demographics, and severity level.2Visser S.N. Bitsko R.H. Danielson M.L. Gandhour R. Blumberg S.J. Schieve L. et al.Treatment of attention-deficit/hyperactivity disorder among children with special health care needs.J Pediatr. 2015; 166: 1423-1429Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar Their most striking finding is that only about one-half of the 4- to 5-year-old preschoolers received the recommended first-line behavioral therapy. Other recent studies also show that the utilization of ADHD guidelines in US community-based pediatric practices remains poor.3Epstein J.N. Kelleher K.J. Baum R. Brinkman W.B. Peugh J. Gardner W. et al.Variability in ADHD care in community-based pediatrics.Pediatrics. 2014; 134: 1136-1143Crossref PubMed Scopus (74) Google Scholar Pediatricians use parent and teacher rating scales during ADHD assessments in only approximately one-half of their patients, and document Diagnostic and Statistical Manual (DSM) criteria in only approximately two-thirds of patients. In community-based practices, the vast majority of children with ADHD receive medication, yet few receive psychosocial services, even when combined treatment approaches have been recommended as the most effective intervention strategies.4The MTA Cooperative GroupMultimodal Treatment Study of Children with ADHDA 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder.Arch Gen Psychiatry. 1999; 56: 1073-1086Crossref PubMed Scopus (2699) Google Scholar Likewise, almost no ADHD care follows AAP ADHD consensus guideline recommendations for the collection of ratings for monitoring treatment outcomes and potential stimulant medication side effects.3Epstein J.N. Kelleher K.J. Baum R. Brinkman W.B. Peugh J. Gardner W. et al.Variability in ADHD care in community-based pediatrics.Pediatrics. 2014; 134: 1136-1143Crossref PubMed Scopus (74) Google Scholar The study by Visser et al provides valuable benchmark data prior to the 2011 AAP guidelines for monitoring future national ADHD diagnostic and treatment patterns. These findings also provide an opportunity to reflect, in general, on the scope and nature of behavioral problems in preschoolers in modern society. Many persons with severe attention deficits, impulsivity, and other ADHD symptoms leading to social and educational difficulties will be helped by pharmacologic treatments. ADHD can be a controversial diagnosis when its signs and symptoms are mild, or even moderate. Recent statistics indicate that most US children diagnosed with ADHD have mild (46.7%) or moderate (39.5%) problems, similar to the parent-reports in the current study from Visser and collagues.2Visser S.N. Bitsko R.H. Danielson M.L. Gandhour R. Blumberg S.J. Schieve L. et al.Treatment of attention-deficit/hyperactivity disorder among children with special health care needs.J Pediatr. 2015; 166: 1423-1429Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 5Centers for Disease Control and Prevention (CDC)Increasing prevalence of parent-reported attention-deficit/hyperactivity disorder among children—United States, 2003 and 2007.MMWR Morb Mortal Wkly Rep. 2010; 59: 1439-1443PubMed Google Scholar Hence, only about 1-in-5 or 1-in-6 children diagnosed with ADHD are considered to have severe ADHD. These dimensions (mild, moderate, and severe) of ADHD are widely recognized as representing the underlying structure of the disorder; but DSM (5th edition) relies on categorical diagnosis to motivate any type of intervention.6Marcus D.K. Barry T.D. Does Attention-deficit/hyperactivity disorder have a dimensional latent structure? A taxometric analysis.J Abnorm Psychol. 2011; 120: 427-442Crossref PubMed Scopus (123) Google Scholar, 7American Psychiatric AssociationDiagnostic and statistical manual of mental health disorders: DSM-5.5th ed. American Psychiatric Publishing, Washington, DC2013Crossref Google Scholar Orthogonal to the concept of dimensionality is the concept of impairment—the extent to which symptoms are impairing a child's quality and progress of life. Both International Classification of Disease and DSM diagnoses now take impairment into account, and there is evidence that evaluations of impairment decrease ADHD prevalence rates.8Döpfner M. Breuer D. Wille N. Erhart M. Ravens-Sieberer U. How often do children meet ICD-10/DSM-IV criteria of attention deficit/hyperactivity disorder and hyperkinetic disorder? Parent-based prevalence rates in a national sample–Results of the BELLA study.Eur Child Adolesc Psychiatry. 2008; 17: 59-70Crossref PubMed Scopus (149) Google Scholar However, impairment is a poorly operationalized concept, left largely to subjective clinical opinion.9Batstra L. Nieweg E.H. Pijl S. Van Tol D.G. Hadders-Algra M. Childhood ADHD: a stepped diagnosis approach.J Psychiatr Pract. 2014; 20: 169-177Crossref PubMed Scopus (10) Google Scholar Thus, neither the acknowledgement of ADHD dimensionality nor the application of the impairment criterion seem likely in the near-term to address the problem of appropriate recognition and management of ADHD-type behaviors in early childhood. The current level of use of stimulant drug treatments in the 4- to 5-year-old preschool population makes this an especially important problem to address quickly. An obvious route to decreasing the use of stimulants in very young children is to increase effectiveness, accessibility, and awareness of the first-line recommended treatments—behavioral interventions. Both the AAP and the United Kingdom National Institute for Clinical Care and Excellence recognize the effectiveness of parent behavior training in preschool children with behavioral problems.10American Academy of PediatricsADHD: clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents.Pediatrics. 2011; 128: 1007-1022Crossref PubMed Google Scholar, 11National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 72. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline. http://guidance.nice.org.uk/CG72/NICEGuidance/pdf/English. Accessed April 13, 2015.Google Scholar The United Kingdom National Institute for Clinical Care and Excellence guidelines specifically do not mention the need for diagnosis in management of child behaviors at this age. The programs of intervention are the same as those recommended for conduct disorder, and the guidelines state that only when “more help is needed” should a child be “referred to a tertiary (psychiatric) service.”11National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 72. Attention deficit hyperactivity disorder: diagnosis and management of ADHD in children, young people and adults. NICE clinical guideline. http://guidance.nice.org.uk/CG72/NICEGuidance/pdf/English. Accessed April 13, 2015.Google Scholar If it is the case that ADHD diagnosis tends to trigger stimulant drug treatment, then providing families access to non-drug interventions without the requirement of a diagnosis at an early stage may reduce the use of stimulant drugs. Such a process might also ensure that only children with more severe cases go forward to diagnosis and drug treatment. Although this may be a common sense approach, behavioral interventions in ADHD are also beset by problems that need to be systematically investigated and resolved. A foundational question is to ask why health professionals are not following guidelines or evidence that opposes use of ADHD drugs among preschoolers. A related question is to ask why parents are accepting drugs to treat behaviors in very young children. Other contextual concerns must also be addressed (and may well intersect with responses to the previous 2 questions). Access to behavioral interventions is unequally distributed across geographic regions.12Chronis A. Jones H.A. Raggi V.L. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder.Clin Psychol Rev. 2006; 26: 486-502Crossref PubMed Scopus (225) Google Scholar Poor access intersects with other barriers to mental health services, which includes parental beliefs, ethnicity, and other factors.13Bussing R. Zima B.T. Gary F.A. Garvan C.W. Barriers to detection, help-seeking and service use for children with ADHD symptoms.J Behav Health Serv Res. 2003; 30: 176-189Crossref PubMed Scopus (226) Google Scholar, 14Ahmed R. McCaffery K.J. Aslani P. Factors influencing parental decision making about stimulant treatment for attention-deficit/hyperactivity disorder.J Child Adolesc Psychopharmacol. 2013; 23: 163-178Crossref PubMed Scopus (28) Google Scholar Part of the problem of poor access is limited access; that is, access to a very limited set of evidence-based interventions. Nevertheless, “behavioral interventions” is a broad spectrum, including parent, home, school, and camp-based programs, often focused on specific impairments and outcomes.12Chronis A. Jones H.A. Raggi V.L. Evidence-based psychosocial treatments for children and adolescents with attention-deficit/hyperactivity disorder.Clin Psychol Rev. 2006; 26: 486-502Crossref PubMed Scopus (225) Google Scholar Although there is some good evidence for these programs, health professionals require training in ensuring a good fit between a family and a particular behavioral intervention. One key to making behavioral and psychological interventions more accessible is the development of internet and mobile technologies-based tools. Telemedicine is reshaping the landscape of mental health service provision, but much more needs to be done both to develop innovative technologies in this area, and to ensure that interventions are safe and effective.15Meyers K, Stoep AV. Children’s telemental ADHD health treatment study (CATTS). http://depts.washington.edu/catts/zdocs/OTHER_INFORMATION.pdf. Accessed March 5, 2015.Google Scholar Adherence to behavioral intervention programs also presents an ongoing challenge, particularly where parents themselves present with stress and psychopathology.16Chronis A.M. Lahey B.B. Pelham Jr., W.E. Kipp H.L. Baumann B.L. Lee S.S. Psychopathology and substance abuse in parents of young children with attention-deficit/hyperactivity disorder.J Am Acad Child Adolesc Psychiatry. 2003; 42: 1424-1432Abstract Full Text Full Text PDF PubMed Scopus (204) Google Scholar In resolving the problem of adherence, the requirement for “evidence-based” interventions may itself result in a paradoxical problem: the “evidence” for a particular intervention is derived from controlled research studies, in which compliance with an intervention is usually highly valued by parents and researchers alike.17Power T.J. Mautone J.A. Soffer S.L. Clarke A.T. Marshall S.A. Sharman J. et al.Family-school intervention for children with ADHD: results of randomized clinical trial.J Consult Clin Psychol. 2012; 80: 611-623Crossref PubMed Scopus (104) Google Scholar More studies of naturalistic intervention settings are required to understand the reasons for and value of adherence to behavioral interventions. Recent studies suggest that more precise operationalization of “adherence” will also be valuable: in citing “poor adherence” to behavioral intervention programs, many studies give statistics on the drop-out rate among parents. However, it may be that parental engagement is more predictive of good outcomes in children, at least on some dimensions, than the number of program sessions attended.18Clarke A.T. Marshall S.A. Mautone J.A. Soffer S.L. Jones H.A. Costigan T.E. et al.Parent attendance and homework adherence predict response to a family-school intervention for children with ADHD.J Clin Child Adolesc Psychol. 2015; 44 (Epub 2013 May 20): 58-67Crossref PubMed Scopus (57) Google Scholar A related, longstanding problem in studies of parenting and ADHD, is that most studies have focused on mothers rather than parents.19Singh I. Boys will be boys: fathers' perspectives on ADHD symptoms, diagnosis, and drug treatment.Harv Rev Psychiatry. 2003; 11: 308-316PubMed Google Scholar Much work needs to be done to develop parent training programs that acknowledge the realities of modern families, in which fathers, same sex partners, and grandparents have taken on an increasing parenting role.20Fabiano G.A. Chacko A. Pelham W.E. Robb J. Walker K.S. Wymbs F. et al.A comparison of behavioral parent training programs for fathers of children with attention-deficit/hyperactivity disorder.Behav Ther. 2009; 40: 190-204Crossref PubMed Scopus (66) Google Scholar One-size parent behavior training is unlikely to fit or appeal to all. Because of the ambiguity surrounding ADHD diagnosis, it is difficult to predict the risks of medicalization and misdiagnosis. This same ambiguity contributes to the problem of over diagnosis and overuse of ADHD medications. However, the increased emphasis on early intervention in child health and well-being presents important opportunities for ecologically oriented research with preschoolers.21Garner A.S. Shonkoff J.P. Siegel B.S. Dobbins M.I. Earls M.F. McGuinn L. et al.Early childhood adversity, toxic stress and the role of the pediatrician: translating developmental science into lifelong health.Pediatrics. 2011; 129: e224-e231PubMed Google Scholar Early intervention programs for toddlers at high risk of developing ADHD are underway.22Zwi M. Jones H. Thorgaard C. York A. Dennis J.A. Parent training interventions for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years.Cochrane Database Syst Rev. 2011; 7: CD003018Google Scholar, 23DuPaul G.J. Young K.L. Young children with ADHD: Early identification and intervention. American Psychological Association, Washington, D.C2011Crossref Google Scholar, 24Jones K. Daley D. Hutchings J. Bywater T. Eames C. Efficacy of the incredible years programme as an early intervention for children with conduct problems and ADHD: long-term follow-up.Child Care Health Dev. 2011; 34: 380-390Crossref Scopus (90) Google Scholar Such studies enable prospective investigation of the clinical and contextual factors that mediate and moderate good outcomes in very young children with behavioral problems. These can include factors as those discussed in this editorial such as early labeling with or without diagnosis, dimensional assessment, and intervention, adherence to and acceptability of treatments.25Singh I. Wessely S. Childhood: a suitable case for treatment?.Lancet Psychiatry. 2015; (in press)Google Scholar The opportunity to add knowledge about the risks and benefits of early intervention programs for preschoolers at risk of ADHD should not be missed. Treatment of Attention Deficit/Hyperactivity Disorder among Children with Special Health Care NeedsThe Journal of PediatricsVol. 166Issue 6PreviewTo describe the parent-reported prevalence of treatments for attention deficit/hyperactivity disorder (ADHD) among a national sample of children with special health care needs (CSHCN), and assess the alignment of ADHD treatment with current American Academy of Pediatrics guidelines. Full-Text PDF