New ADHD guidelines could increase treatment in preschoolers and high schoolers

By Deborah Kotz, Globe Staff

New guidelines for diagnosing and treating attention deficit hyperactivity disorder could lead pediatricians to diagnose the condition in kids as young as four and to continue treating teens through high school on stimulant drugs like Ritalin and Adderall. The recommendations, released today at the American Academy of Pediatrics annual meeting in Boston, state that primary care physicians should do a diagnostic workup and initiate treatment for ADHD for any child aged 4 through 18 who has academic or behavioral problems and has trouble with inattention, hyperactivity, or impulsivity.

The previous guidelines issued a decade ago only applied to children aged 6 through 12 since at that time, there a was a lack of research in preschoolers and teens, according to Dr. Mark Wolraich, chair of the guideline committee.

Besides expanding the age range, “we wanted to strongly remind physicians that this is a chronic illness,” said Wolraich, “and if anything we’ve fallen down in the care of children” who, once they reach high school, stop taking their medications only to see a return of symptoms.

(Wolraich, a professor of pediatrics at the University of Oklahoma Health Sciences Center, has served as a consultant to several pharmaceutical firms that manufacture drugs for the treatment of ADHD. Most of the 15 members of the guideline writing committee had no conflicts.)

An estimated 5 percent of American school-age children have been diagnosed with ADHD or its cousin, attention deficit disorder, and questions have been raised concerning the overdiagnosis and overtreatment of the disorders in those with mild behavioral problems that fall into the normal range of behavior. Two studies last year found that the youngest kids in the class -- who are more likely be less mature than their peers -- were more likely to be diagnosed with ADHD.

In a blog posted today, pediatrician Claudia Gold, author of the book Child in Mind, argued that extending the diagnosis down to age 4 is very worrisome. “There is a wide range of maturity rate,” Gold wrote. “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.”

Of course, many parents have found that diagnosis and treatment for the condition has provided their children with a much-needed life preserver enabling them to overcome learning deficits and achieve their academic potential.

Wolraich said the intent of the new guidelines was to cut down on overdiagnoses by providing physicians with better diagnostic criteria while also identifying children who have gone undiagnosed and untreated. For preschoolers, the guidelines recommend behavior therapy as a first-line treatment followed by a medication like Ritalin only if the therapy hasn’t worked. He added that high schoolers being treated with drugs for ADD or ADHD don’t necessarily need to remain on medication but should be closely monitored to see whether their schoolwork suffers if they go off their medications.

“We didn’t specifically come out with recommendations on whether teens should stop medications since to some extent, it’s individual for each patient,” Wolraich said. Some teens, for example, go off their stimulants around holiday times since they can suppress appetite and make holiday dinners less enjoyable. Others find they can taper off on weekends or during the summer.

Doctors may need to adjust medications and doses as teens grow or go through puberty, the guidelines stress. Some may develop severe insomnia from stimulant drugs and may be better off switching to a non-stimulant drug like Strattera or Intuniv. Others may need to switch to higher doses.

How much impact the new guidelines will have on the diagnosis and treatment of ADHD remains to be seen. Physicians are often slow to adopt new recommendations, though many are already treating ADHD in preschoolers.

No question, though, more children could “potentially be on [drug] treatments for longer periods” as a result of the new recommendation, said Dr. Carole Allen, who retired this month as director for pediatrics for Harvard Vanguard Medical Associates, and is a member of the AAP board of directors who reviewed and approved the new guidelines. “This is an instance of the benefit outweighing the risk.”

In an e-mail, she said she thinks “most pediatricians will be pretty cautious in their use of medications in young children and will consult with mental health professionals for guidance.”

Dr. Marilyn Augustyn, a developmental and behavioral pediatrician at Boston Medical Center, said via e-mail that she welcomed the new policy -- which she played no role in developing -- and considered it an “improvement on the old one” since, among other things, it included a broader discussion on behavioral treatment approaches like preschool special education services that urge positive reinforcement for good behavior.

Deborah Kotz can be reached at dkotz@globe.com. Follow her on Twitter @debkotz2.