Preschool ADHD Treatment Study Research Articles

Diagnosis and Treatment Options for Preschoolers with Attention-Deficit/Hyperactivity Disorder.

Objective: The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), classifies attention-deficit/hyperactivity disorder (ADHD) as a neurodevelopmental disorder, with symptoms becoming apparent as early as the preschool years. Early recognition can lead to interventions such as parent/teacher-administered behavior therapy, the recommended first-line treatment for preschool patients. There are few data, however, to inform the use of second-line, pharmacotherapy options in this population. In this review, we identified recent literature on the diagnosis and treatment of ADHD in preschool children. Methods: A PubMed and clinicaltrials.gov search was conducted for trials assessing efficacy or safety of ADHD medications in children aged <6 years. Diagnostic methods and criteria focusing on recognition of ADHD in preschool children were also surveyed. Results: The DSM-5 describes different manifestations of ADHD in preschool versus school-aged children, but does not list separate criteria by age group. Importantly, behaviors indicative of ADHD in older children may be developmentally appropriate in preschool children. Several behavioral rating scales have been validated in children younger than 6 years of age for assessing ADHD. The Preschool ADHD Treatment Study (PATS) has provided the most extensive efficacy and safety data on methylphenidate (MPH) for ADHD in preschoolers to date, with significant improvement in ADHD symptoms observed with MPH compared with placebo, although adverse event-related discontinuation was higher in PATS compared with studies of MPH for ADHD in school-aged children. Since PATS was conducted, few studies designed to assess ADHD medication effectiveness in preschool children have been published. One article reported significant improvement in ADHD symptoms with MPH (immediate release) versus placebo, two studies showed no difference between MPH and risperidone or MPH plus risperidone in relief of ADHD symptoms, and one study demonstrated the efficacy of atomoxetine versus placebo for ADHD symptoms in preschoolers. Conclusions: Further research is needed on pharmacotherapy for preschool children with ADHD.

Attention-Deficit/Hyperactivity Disorder: A Historical Neuropsychological Perspective.

The behavior patterns of hyperactivity, impulsivity and inattention that would ultimately become recognized as Attention-Deficit Hyperactivity Disorder (ADHD) have been described for centuries. Nevertheless, in the past 35 years, advances in diagnostic methods, identification of biomarkers, and treatments have advanced at an exponential rate. ADHD is now recognized as the most common behavioral disorder of childhood, with risks extending well into adulthood for both males and females, leading to its identification as a significant public health issue. This historical neuropsychological review of ADHD emphasizes scientific highlights in the past 35 years related to ADHD, including the evolution of the diagnosis (from Hyperkinetic Reaction of Childhood to ADHD), influential theories (executive functions, cognitive-energetic, delay aversion), landmark treatment studies (Multimodal Treatment of ADHD [MTA] and Preschool ADHD Treatment Study [PATS]), and advances in brain mapping techniques (anatomic, functional, and resting state magnetic resonance imaging, diffusion tensor imaging). The review concludes by highlighting the challenges of studying and treating a heterogeneous neurodevelopmental disorder like ADHD, with emphasis on associated disorders and conditions (learning disabilities, sluggish cognitive tempo), special populations (girls, preschoolers, adults), and recommendations for scientific inquiry in the next 35 years. Neuropsychologists are well positioned to address the clinical and research challenges of the next generation of studies, especially involving advances in understanding the sexual dimor.phism, full developmental course, and dynamic risks associated with ADHD. (JINS, 2017, 23, 916-929).

ADHD meds in preschool likely to be continued in school‐age children

Attention‐deficit hyperactivity disorder (ADHD) is usually first diagnosed and treated at the beginning of elementary school, which is a problem for those children who have severe and impairing symptoms in preschool years. The Preschool ADHD Treatment Study (PATS), a controlled clinical trial published almost 10 years ago, found that methylphenidate was effective in preschoolers with severe ADHD. Subsequent studies found that ADHD diagnosed in preschool persists through school‐age years. However, little is known about long‐term pharmacotherapy for children first treated with methylphenidate — whether stimulants are added or substituted, in particular. For parents asking about the type and duration of treatment, this information would be useful, as well as important to clinicians and researchers. So for this study, researchers wanted to look at the treatment of children first diagnosed with the disorder as preschoolers and how they fared over time. Longitudinal data are critically important but hard to come by, given the difficulty of maintaining the participation of the research group and a constant source of research support to carry out the follow‐up evaluations.

Pharmacotherapy of the Preschool ADHD Treatment Study (PATS) Children Growing Up

To describe the long-term psychopharmacological treatment of children first diagnosed with attention-deficit/hyperactivity disorder (ADHD) as preschoolers. In a systematic, prospective, naturalistic follow-up, 206 (68.0%) of the 303 children who participated in the Preschool ADHD Treatment Study (PATS) were reassessed 3 years (mean age 7.4 years) and 179 (59.1%) were reassessed 6 years (mean age 10.4 years) after completion of the controlled study. Pharmacotherapy and clinical data were obtained from the parents. Pharmacotherapy was defined as use of a specific class of medication for at least 50% of the days in the previous 6 months. At year 3, a total of 34.0% of the participants were on no pharmacotherapy, 41.3% were on stimulant monotherapy, 9.2% were on atomoxetine alone or with a stimulant, 8.3% were on an antipsychotic usually together with a stimulant, and the remaining 7.2% were on other pharmacotherapy; overall, 65.0% were on an indicated ADHD medication. At year 6, a total of 26.8% of the participants were on no pharmacotherapy, 40.2% were on stimulant monotherapy, 4.5% were on atomoxetine alone or with a stimulant, 13.4% were on an antipsychotic, and 15.1% were on other pharmacotherapy; overall, 70.9% were on an indicated ADHD medication. Antipsychotic treatment was associated with more comorbidity, in particular disruptive behavior disorders and pervasive development disorders, and a lower level of functioning. In this study, the long-term pharmacotherapy of preschoolers with ADHD was heterogeneous. Although stimulant medication continued to be used by most children, about 1 child in 4 was off medication, and about 1 in 10 was on an antipsychotic.

The Preschool Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS) 6-Year Follow-Up

To describe the clinical course of attention-deficit/hyperactivity disorder (ADHD) symptom severity and diagnosis from ages 3 to 5 up to 9 to 12 years during a 6-year follow-up after the original Preschool ADHD Treatment Study (PATS). A total of 207 participants (75% male) from the original PATS, assessed at baseline (mean age, 4.4 years, when all met criteria for ADHD) and 3 months later (before medication treatment), were re-evaluated in three follow-up assessment visits (year 3, mean age 7.4 years; year 4, 8.3 years; and year 6, 10.4 years). Parents and teachers rated symptom severity, and clinicians established psychiatric diagnoses. Analyses examined longitudinal changes in symptom severity and ADHD diagnosis. Parent- and teacher-rated symptom severity decreased from baseline to year 3 but remained relatively stable and in the moderate-to-severe clinical range through year 6. Girls showed generally steeper decreases in symptom T-scores. At year 6, 89% (160/180) of remaining participants met ADHD symptom and impairment diagnostic criteria. Comorbidity of oppositional defiant disorder and/or conduct disorder was associated with a 30% higher risk of having an ADHD diagnosis at year 6 in the multiple logistic model. Medication status during follow-up, on versus off, did not predict symptom severity change from year 3 to year 6 after adjustment for other variables. ADHD in preschoolers is a relatively stable diagnosis over a 6-year period. The course is generally chronic, with high symptom severity and impairment, in very young children with moderate-to-severe ADHD, despite treatment with medication. Development of more effective ADHD intervention strategies is needed for this age group.

Pharmacologic Intervention for Attention-Deficit Hyperactivity Disorder in Preschoolers

Pharmacologic intervention for attention-deficit hyperactivity disorder (ADHD) in preschool children is a controversial issue. Non-pharmacologic interventions (psychosocial and restricted dietary interventions) have been shown to benefit oppositional, non-compliant, aggressive and disruptive, as well as hyperactive and inattentive behaviors in preschoolers with ADHD and other disruptive behavior disorders. However, not all families have access to non-pharmacologic interventions or prefer them. The Preschool ADHD Treatment Study recently provided evidence of benefit with immediate-release methylphenidate; however, effect sizes were small to moderate and preschoolers had a high rate of adverse effects and a unique adverse effect profile. Furthermore, no information is available about long-term safety and effects of psychopharmacologic agents on the rapidly developing brains of preschoolers. Based on current evidence and guidelines, a careful trial with psychopharmacologic agents is indicated to treat ADHD in preschoolers if there is no improvement with behavior therapy and the preschoolers continue to exhibit significantly impaired hyperactive and inattentive symptoms. Preschoolers should be monitored closely for adverse effects and tried off medications after 6 months to assess the need for ongoing psychopharmacologic intervention. Further research is needed to identify predictors and moderators of response to guide individualized/optimal treatment options for ADHD in preschoolers.

ADHD Pharmacotherapy: Rates of Stimulant Use and Cardiovascular Risk

ADHD Pharmacotherapy: Rates of Stimulant Use and Cardiovascular Risk

ADHD Comorbidities: Handbook for ADHD Complications in Children and Adultsedited by BrownThomas E., Ph.D., Washington, DC, American Psychiatric Publishing, 2009, 478 pp., $99.00.

Back to table of contents Previous article Next article Communications and UpdatesFull AccessADHD Comorbidities: Handbook for ADHD Complications in Children and AdultsManpreet Kaur Singh, M.D., M.S.,Manpreet Kaur SinghSearch for more papers by this author, M.D., M.S.,Published Online:1 May 2011https://doi.org/10.1176/appi.ajp.2011.11010072AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail edited by BrownThomas E., Ph.D., Washington, DC, American Psychiatric Publishing, 2009, 478 pp., $99.00.In recognition of the fact that attention deficit hyperactivity disorder (ADHD) is a complex disorder, with the co-occurrence of other psychiatric disorders being among the most challenging complications, this textbook provides a comprehensive review of how ADHD relates to other disorders and how this interaction can be effectively recognized and treated. In addition, the book provides updated information about developmental aspects of ADHD not current in its preceding volume (Attention-Deficit Disorders and Comorbidities in Children, Adolescents, and Adults, published in 2000). To my knowledge, there are few definitive textbooks that cover this clinical disorder over the life span and provide a developmental context for its various presentations over time. Moreover, phenomenological descriptions are not limited to DSM criteria but rather integrated with the rich knowledge gained about this disorder from the field of neuroscience. After establishing the developmental complexities, genetics, and common presentations of ADHD from preschool to adulthood, the body of the book focuses on the co-occurrence of the disorder with a variety of psychiatric syndromes, including mood and anxiety disorders, oppositionality and aggression, obsessive-compulsive disorders, language and learning disorders, substance use disorders, autism spectrum disorders, developmental coordination disorder, sleep disturbances, and Tourette's syndrome. This thematic organization is helpful not only to a clinician but also to educators and laypersons, who might observe attentional problems manifested in a variety of different contexts outside of a clinical setting.Compared with the earlier edition of this book, interim knowledge has suggested conceptual models of ADHD that embrace its heterogeneity among individuals and its susceptibility to change across development and environmental variations. In addition, ADHD is no longer considered simply a disorder of executive function as defined by neuropsychological tests but rather a complex syndrome of impairments across multiple overlapping cognitive operations, including motivation and emotion regulation. This book also makes the point that whereas early studies cautioned against the use of psychostimulant therapy for individuals with ADHD and comorbid conditions such as mood or anxiety disorders, recent literature suggests that many patients may in fact benefit from such treatment. This new framework is illustrative of the contemporary view that individual patients rarely have symptoms that fit neatly into unified diagnostic groups. Moreover, treatment should be tailored to target overlapping symptoms and dimensional features and should incorporate pertinent sources of stress and support. Although controversies abound regarding the diagnosis and treatment of highly comorbid conditions such as ADHD, DSM-5 work groups are being challenged to consider alternative views of psychiatric diagnoses that incorporate these types of complexities. In this way, this textbook will prove to be an excellent compendium to the DSM, focused specifically on attentional dysfunction and related disorders.As a child psychiatrist and pediatrician, I found myself drawn to the case vignettes, information about clinical course with complicated ADHD, and treatment recommendations. Each chapter ends with key clinical bullets, recommended readings, and Internet resources, all useful tools for a busy clinician. The chapters at the end of the book provide another level of guidance on the assessment and intervention of ADHD, synthesizing special considerations described in the preceding chapters. It would be nice to see more speculation on gaps in current knowledge and what kind of study designs will help advance research in this field. For example, although much has been learned in the past decade about the benefits of certain medications and behavioral approaches for the treatment of ADHD from the Preschool ADHD Treatment Study, the Multimodal Treatment Study of Children with ADHD, and the National Comorbidity Survey Replication, few studies have helped us optimize treatments and outcomes for individuals with predominantly ADHD inattentive type, familial ADHD, or ADHD as a result of a perinatal developmental insult (e.g., fetal alcohol syndrome). If advancements in the past decade are any indication of the trajectory of knowledge gained in this field, I look forward to the next generation of studies that will provide even greater levels of sophistication in the evaluation and treatment of ADHD.Stanford, Calif.Book review accepted for publication January 2011.Dr. Singh receives research grant support from the Klingenstein Third Generation Foundation, the National Alliance for Research on Schizophrenia and Affective Disorders, the National Institute of Mental Health (Grant MH085919), the American Psychiatric Association, and Stanford's Child Health Research Program. FiguresReferencesCited byDetailsCited ByCurrent World LiteratureCurrent Opinion in Psychiatry, Vol. 25, No. 3 Volume 168Issue 5 May 2011Pages 555-555 Metrics PDF download History Accepted 1 January 2011 Published online 1 May 2011 Published in print 1 May 2011

Review of ADHD Pharmacotherapies: Advantages, Disadvantages, and Clinical Pearls

Pharmacotherapy for the treatment of attention-deficit/hyperactivity disorder (ADHD) originally consisted primarily of stimulant medications in immediate-release preparations dosed multiple times per day. Data demonstrating the efficacy of these stimulant medications for the treatment of ADHD and their role in treating children was well established by the 1970s. Multiple formulations of the stimulant medications have subsequently been developed during the past 40 years. Recent studies, including the NIMH Collaborative Multisite Multimodal Treatment Study of Children With Attention-Deficit/Hyperactivity Disorder and the Preschool ADHD Treatment Study, have helped to clarify the role of stimulant medications in the treatment of ADHD.

Research on Children Yielding Valuable Clinical Information

Research on Children Yielding Valuable Clinical Information

Clinical Presentation of Attention-Deficit/Hyperactivity Disorder in Preschool Children: The Preschoolers with Attention-Deficit/Hyperactivity Treatment Study (PATS)

The aim of this study was to describe the clinical presentation of preschoolers diagnosed with moderate to severe attention-deficit/hyperactivity disorder (ADHD) recruited for the multisite Preschool ADHD Treatment Study (PATS). The diagnosis and evaluation process will also be described. A comprehensive multidimensional, multi-informant assessment protocol was implemented including the semistructured PATS Diagnostic Interview. Parent and teacher-report measures were used to supplement information from interviews. Consensus agreement by a cross-site panel on each participant's diagnoses was required. Analyses were conducted to describe the sample and to test associations between ADHD severity and demographic and clinical variables. The assessment protocol identified 303 preschoolers (3-5.5 years) with moderate to severe ADHD Hyperactive/Impulsive or Combined type. The majority of participants (n = 211, 69.6%) experienced co-morbid disorders, with oppositional defiant disorder, communication disorders, and anxiety disorders being the most common. Participants with co-morbid communication disorders were found to be more anxious and depressed. ADHD severity was found to correlate with more internalizing difficulties and lower functioning. Although boys and girls had similar symptom presentations, younger children had significantly higher ADHD severity. Preschoolers with moderate to severe ADHD experience high co-morbidity and impairment, which have implications for both assessment and treatment.

Factor Structure of Parent- and Teacher-Rated Attention-Deficit/Hyperactivity Disorder Symptoms in the Preschoolers with Attention-Deficit/Hyperactivity Disorder Treatment Study (PATS)

This study examines one-, two-, and three-factor models of attention-deficit/hyperactivity disorder (ADHD) using the existing 18 Diagnostic and Statistical Manual of Mental Disorder, 4th edition (DSM-IV) symptoms in a sample of symptomatic preschoolers. Parent and/or teacher ratings of DSM-IV symptoms were obtained for 532 children (aged 3-5.5) who were screened for the Preschool ADHD Treatment Study (PATS). Confirmatory factor analysis (CFA) using symptoms identified on the Conners' Parent and Teacher Rating Scales was conducted to assess a two-factor model representing the DSM-IV dimensions of inattention (IN) and hyperactivity/impulsivity (H/I), a three-factor model reflecting inattention, hyperactivity, and impulsivity, and a single-factor model of all ADHD symptoms. Exploratory factor analysis (EFA) was subsequently used to examine the latent structure of the data. For parent ratings, the two-factor and three-factor models were marginally acceptable according to several widely used fit indices, whereas the one-factor model failed to meet minimum thresholds for goodness-of-fit. For teachers, none of the models was a solid fit for the data. Maximum likelihood EFAs resulted in satisfactory two and three-factor models for both parents and teachers, although all models contained several moderate cross loadings. Factor loadings were generally concordant with those published for older children and community-based samples. ADHD subtypes according to current DSM-IV specifications may not be the best descriptors of the disorder in the preschool age group.

Preschoolers With ADHD May Benefit From Stimulants

Preschoolers With ADHD May Benefit From Stimulants

Rationale, Design, and Methods of the Preschool ADHD Treatment Study (PATS)

To describe the rationale and design of the Preschool ADHD Treatment Study (PATS). PATS was a National Institutes of Mental Health-funded, multicenter, randomized, efficacy trial designed to evaluate the short-term (5 weeks) efficacy and long-term (40 weeks) safety of methylphenidate (MPH) in preschoolers with attention-deficit/hyperactivity disorder (ADHD). Three hundred three subjects ages 3 to 5.5 years old who met criteria for a primary DSM-IV diagnosis of ADHD entered the trial. Subjects participated in an 8-phase, 70-week trial that included screening, parent training, baseline, open-label safety lead-in, double-blind crossover titration, double-blind parallel efficacy, open-label maintenance, and double-blind discontinuation. Medication response was assessed during the crossover titration phase using a combination of parent and teacher ratings. Special ethical considerations throughout the trial warranted a number of design changes. This report describes the design of this trial, the rationale for reevaluation and modification of the design, and the methods used to conduct the trial. The PATS adds to a limited literature and improves our understanding of the safety and efficacy of MPH in the treatment of preschoolers with ADHD, but changes in the design and problems in implementation of this study impose some specific limitations that need to be addressed in future studies.

Stimulant-Related Reductions of Growth Rates in the PATS

To investigate growth of children with attention-deficit/hyperactivity disorder (ADHD) in the Preschool ADHD Treatment Study (PATS) before and after initiation of treatment with methylphenidate at titrated doses (average, 14.2 mg/day) administered three times daily, 7 days/week for asymptotically equal to1 year. The heights and weights of 140 children with ADHD were measured up to 29 times in the PATS protocol, starting at an average age of 4.4 years. The relationship between standard (z) scores and time on medication was examined using mixed-effect regression to estimate change in relative size (slope). Average relative size at baseline was significantly (p<.0001) greater than zero for z height (+0.45) and z weight (+0.78), indicating greater than expected height (by 2.04 cm) and weight (by 1.78 kg). During treatment, slopes were significantly (p<.0001) less than zero for z height (-0.304/yr) and z weight (-0.530/yr), indicating reduction of growth rates. For 95 children who remained on medication, annual growth rates were 20.3% less than expected for height (5.41 cm/yr-6.79 cm/yr=-1.38 cm/yr) and 55.2% for weight (1.07 kg/yr-2.39 kg/yr=-1.32 kg/yr). Risks of reduced growth rates should be balanced against expected benefits when preschool-age children are treated with stimulant medication.

Efficacy and Safety of Immediate-Release Methylphenidate Treatment for Preschoolers With ADHD

The Preschool ADHD Treatment Study (PATS) was a NIMH-funded, six-center, randomized, controlled trial to determine the efficacy and safety of immediate-release methylphenidate (MPH-IR), given t.i.d. to children ages 3 to 5.5 years with attention-deficit/hyperactivity disorder (ADHD). The 8-phase, 70-week PATS protocol included two double-blind, controlled phases, a crossover-titration trial followed by a placebo-controlled parallel trial. The crossover-titration phase's primary efficacy measure was a combined score from the Swanson, Kotkin, Atkins, M-Flynn, and Pelham (SKAMP) plus the Conners, Loney, and Milich (CLAM) rating scales; the parallel phase's primary outcome measure was excellent response, based on composite scores on the Swanson, Nolan, and Pelham (SNAP) rating scale. Of 303 preschoolers enrolled, 165 were randomized into the titration trial. Compared with placebo, significant decreases in ADHD symptoms were found on MPH at 2.5 mg (p<.01), 5 mg (p<.001), and 7.5 mg (p<.001) t.i.d. doses, but not for 1.25 mg (p<.06). The mean optimal MPH total daily dose for the entire group was 14.2 +/- 8.1 mg/day (0.7+/-0.4 mg/kg/day). For the preschoolers (n=114) later randomized into the parallel phase, only 21% on best-dose MPH and 13% on placebo achieved MTA-defined categorical criterion for remission set for school-age children with ADHD. MPH-IR, delivered in 2.5-, 5-, and 7.5-mg doses t.i.d., produced significant reductions on ADHD symptom scales in preschoolers compared to placebo, although effect sizes (0.4-0.8) were smaller than those cited for school-age children on the same medication.

The Role of Stimulants in the Treatment of Preschool Children with Attention-Deficit Hyperactivity Disorder

The symptoms of attention-deficit hyperactivity disorder (ADHD) can have an early onset, beginning before the age of 6 years. Despite the significant number of preschool-aged children that can be diagnosed with ADHD, there are limited controlled data available on the pharmacological interventions being increasingly used in this population. A 1990 review showed that 34% of paediatricians and 15% of family physicians had prescribed psychostimulant medications to preschoolers with ADHD, and pharmacoepidemiological studies indicate growing use of stimulants in preschoolers during the 1990s. Unfortunately, only six controlled trials, with a total enrollment of less than 200 children, have been conducted using these drugs in preschoolers. While these small studies provide some evidence of benefit from the use of methylphenidate in preschoolers with ADHD, more data are critically needed. Practice parameters developed by the American Academy of Child & Adolescent Psychiatry and the American Academy of Pediatrics provide some guidance regarding the diagnosis and treatment of young children with ADHD, but are mainly based upon research in children of primary-school age. The ongoing PATS (Preschool ADHD Treatment Study), funded by the National Institute of Mental Health, will provide important clinical guidance for diagnostic considerations and intervention strategies for children with ADHD aged 3-5 years. Pending the release of data from the PATS study, clinicians must rely on developmental assessment skills, available standardised rating instruments, reports about the child from multiple informants, and knowledge of the risks and benefits of available pharmacological and behavioural treatments, in order to treat preschool children with ADHD effectively.