New Research on ADHD Treatment Outcomes
by Richard Rubin, MD
Clinical Associate Professor, University of Vermont
College of Medicine

Useful observations from the third year of the Multimodality Treatment of ADHD Study (MTA) were published in the August 2007 Journal of the American Academy of Child and Adolescent Psychiatry. This report attempts to fill some of the gaps in our understanding of long-term outcomes and their relationship to medication persistence. In the study's first fourteen months, 579 Combined type ADHD seven to nine year olds were randomly assigned to one of four groups: intensive medication, behavior therapy, combined medicine and therapy, or community care as the families arranged. Afterwards, the families could choose the form of continuing treatment, and the six university teams of investigators assessed outcomes of the 485 children who completed three years.

While the medication and combined groups had superior benefit over behavior therapy and community care after 14 months, this advantage disappeared after three years. Changes on or off medication were frequent. Use in the original intensive medication group declined to 71%, and in the behavior therapy alone group, it increased to 45%. Interestingly, the community care group started and continued at approximately 60% receiving medication. The use of education support services remained similar in all groups.

A second major finding is similar eventual ADHD core symptom improvement in all of the original groups. However, this does not mean that all types of therapy work equally well. Three distinct outcome courses emerged: 1) 34% had gradual, ongoing improvement, 2) 52% showed a large symptom decrease initially that was maintained, and 3) 14% had some initial improvement, but gradually relapsed to their original degree of problems. This poor outcome group was distinguished by higher initial symptom scores, more aggressive behavior, lower IQ's, and less social skills.

Recognizing these outcome factors can help clinicians plan and evaluate treatments. The authors suggest that best medication outcome may require intensive initial treatment and continuation. However, others who started later when their ADHD worsened obtained less benefit. Further analysis of the MTA is ongoing.

Dr. Rubin practices Child and Adult Psychiatry, directs The Clinical Study Center in Burlington Vermont, and serves as Clinical Associate Professor at the University of Vermont College of Medicine.

• The Neurology of Attention Deficit Hyperactivity Disorders
• Major Follow Up Study Following ADHD Treatment

Diagnosing Preschool Children with ADHD
by Arlene Schusteff

Is it possible to diagnose attention deficit disorder (ADD ADHD) in preschool children? A new study provides insight.

Mary K., of Hillside, New Jersey, suspected that her son, Brandon, should be diagnosed with attention deficit disorder. He was unusually active from the time he was born. "Brandon jumped out of his crib at age one, and hasn't stopped moving, climbing, and jumping since." At first, Mary and her husband ascribed Brandon's high activity level to "boys being boys". But when the preschool he attended asked the three-year-old to leave because of concerns about his aggressive and impulsive behaviors, she began to suspect a bigger problem.

At home, life was no easier. "Brandon drew on the walls and didn't listen to anything we said. He threw pictures or silverware across the room when he was frustrated, which was all the time. We lived and died by Brandon's moods. If he was in a good mood, everyone in the house was in a good mood, and vice versa. I had a three-year-old running my household," says Mary.

Mary and her husband stopped inviting relatives to their home because they were embarrassed by their lack of control over their preschooler and his ADHD behaviors. "Friends began to shy away from us-they didn't want their children to be around him. I felt like the worst mother in the world."

An elementary school disorder?

After Brandon was asked to leave a second preschool-he'd chased a girl around the playground with a plastic knife, saying he would "cut her up"-Mary booked an appointment with her son's pediatrician to ask about diagnosing the preschooler with attention deficit disorder. Her doctor's response, however, was that Brandon was much too young for an ADHD diagnosis. And this response is one that parents of children with ADHD across the country in similar circumstances can expect to encounter. Why?

Attention deficit disorder has traditionally been viewed as a disorder of elementary school children. While there are hundreds of scientific studies generating a wealth of data for diagnosing and treating ADHD in school-age children, there are few equivalent studies about diagnosing and treating preschoolers with ADHD. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria used to diagnose ADHD include symptoms such as, "out of seat during school," "does not follow through on instructions," "avoids tasks with sustained mental effort," and "fidgety and restless while sitting"-describing behaviors that may be developmentally appropriate for some preschoolers.

Diagnosing ADHD in preschoolers
s it possible, then, to diagnose children with attention deficit disorder when impulsivity, opposition, and extreme activity are normal preschool behaviors? Yes, but the tipping point in diagnosis is usually a matter of degree. "Children with ADHD are much more extreme than the average three-year-old," says Alan Rosenblatt, M.D., a specialist in neurodevelopmental pediatrics. "It's not just that a child with ADD can't sit still. It's that he can't focus on any activity, even one that's pleasurable, for any length of time."

Larry Silver, M.D., a psychiatrist at Georgetown University School of Medicine, says that an experienced teacher, one with a baseline of appropriate three-year-old behavior, can be a tremendous help. "You have to look at whether or not the behaviors are consistent in more than one environment," he notes.

But experts caution that, even with "red flags," early diagnosis of ADHD can be difficult. "You have to delve deep into the root of certain behaviors," says Silver. "A child might have separation anxiety, his fine motor skills or sensory problems could be making it hard for him to behave, or it could be evolving Pervasive Developmental Disorder," he says.

Nonetheless, Laurence Greenhill, M.D., of Columbia University/New York State Psychiatric Institute, points to two behavioral patterns that often predict ADHD diagnosis later in life. The first, preschool expulsion, is usually caused by aggressive behavior, refusal to participate in school activities, and failure to respect other children's property or boundaries. The second, peer rejection, is one that parents can easily identify. Children with extreme behaviors are avoided by their classmates, shunned on the playground. Other children are "busy" whenever parents try to arrange playdates.

In these extreme cases, parents should take their preschooler to a pediatrician or a child psychiatrist. Diagnosis of ADHD should involve a thorough medical and developmental history, observation of social and emotional circumstances at home, and feedback from teachers and health professionals who have contact with the child. In many cases, neuropsychological testing may be needed to rule out conditions whose symptoms might overlap with ADHD, including anxiety disorder, language-processing disorders, oppositional-defiant disorders, and sensory integration problems.

Treatment Options

If your preschool child is diagnosed with ADHD, what is the next step? Both the American Psychological Association and the American Academy of Child and Adolescent Psychiatry advise that ADHD treatment in children proceed according to the severity of the symptoms. For children who play well with others and who have healthy self-esteem, Carol Brady, Ph.D., a child psychologist in Houston, says that environmental changes can help. "A smaller classroom, with less stimulation, and a strong routine often make a tremendous difference in improving ADHD symptoms in preschoolers."

In most cases, parent effectiveness training or behavior therapy is the next course of action (see sidebar, at left, The Preschool ADHD Treatment Study (PATS)). There is increasing evidence that treating ADHD symptoms in preschoolers can be extremely effective, even for children with a high degree of impairment. But what if your child with ADHD doesn't respond to behavioral interventions? Is ADHD medication the answer? Methylphenidate (brand names include Ritalin and Concerta) is the most commonly prescribed medication to treat children diagnosed with ADHD, but it is not approved by the Food and Drug Administration for use in children younger than six.

The Preschool ADHD Treatment Study, or PATS, conducted by the National Institute of Mental Health (NIMH), is the first long-term study designed to evaluate the effectiveness of treating preschoolers with ADHD with behavioral therapy, and then, in some cases, methylphenidate. In the first stage, the children (303 preschoolers with severe ADHD, between the ages of three and five) and their parents participated in a 10-week behavioral therapy course. For one third of the children, ADHD symptoms improved so dramatically with behavior therapy alone that they did not progress to the ADHD medication phase of the study.

This article was reprinted with permission from ADDitude Magazine. Visit Additude Magazine for more information.

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