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Doctors Deviate From Guidelines When Treating ADHD in Preschoolers

In 2011, the American Academy of Pediatrics released guidelines on how doctors should treat preschoolers with attention deficit hyperactivity disorder. The first step should be parent and/or teacher-administered behavioral therapy. If symptoms continue, the next step is medication with methylphenidate, better known under the brand names Ritalin or Concerta.

But only about 10 percent of medical specialists responding to a survey on their treatment methods said that they followed those guidelines exactly. Many chose medication as a first-line treatment; others chose to prescribe different types of medication, or refused to prescribe drugs even when behavioral therapy was not showing success.

The findings were released at a recent meeting devoted to research in child development, the Pediatric Academic Societies.

Dr. Anthony Adesman, one of the study's authors and the chief of behavioral and development pediatrics at Cohen Children's Medical Center of New York, said that a survey was sent to 3,000 preschool ADHD specialists and received 714 surveys in return. The results were limited to 614 specialists who say they diagnose preschool ADHD in 4- and 5-year-olds, including child psychiatrists, neurologists, and developmental pediatricians. The full report is not available online, but Dr. Adesman shared with me his presentation, which offers a detailed breakdown of the numbers.

His survey found that of the 611 specialists in preschool ADHD who responded, about 20 percent said they recommended first-line treatment with medication "often" or "very often." The recommendations were made regardless of the availability of behavioral therapy options.

About 30 percent said they "rarely" or "sometimes" recommend medication if modifying the child's behavior has not been successful.

The survey also found that some doctors were choosing to prescribe drugs other than methylphenidate. Though the AAP recommends that only that particular drug be used with 4- and 5-year-olds, about 19 percent of the respondents are choosing to use amphetamines such as Adderall or Dexedrine, Dr. Adesman said. (Both drugs are approved in children ages 3 or older.) Another 18 percent are prescribing other non-stimulant drugs for ADHD treatment. One such drug, Clonidine, is FDA-approved for use in youth aged 6 or older.

Among the specialists surveyed, only about 10 percent said they followed AAP recommendations exactly. Those most likely to adhere to the AAP guidelines were child psychiatrists; 12 percent of the survey respondents who were child psychiatrists followed those recommendations. The general psychiatrists who responded to the survey were least likely to follow the guidelines exactly; only 4 percent said they did.

In an interview, Dr. Adesman said that the results could reflect that children who see specialists may have more severe symptoms, or that doctors are more familiar with medications. However, another explanation could be that some doctors "are reluctant to recommend behavior therapy, or to give it a chance."

Teachers can play a meaningful and important role in implementing behavior modification techniques with young children, Dr. Adesman said. He also added that medication has a place in treating ADHD if other methods are not successful. "Teachers may want to educate parents that the AAP does see medication as a possible option," he said.

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