Jack Maypole, MD
Jack Maypole, MD
Director
Comprehensive Care Program, Boston Medical Center
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What Now? On Treating Younger Kids with ADHD


Halley was four when her mother brought her in from preschool, after she’d been asked to leave (again!) due to her challenging behavior. Halley had always been busy, sure. Increasingly, she struggled with what the teacher described as “taking turns and controlling herself.”

“I’m now officially worried,” Halley’s mother said. “I’ve heard about new recommendations for treating ADHD [Attention Deficit Hyperactivity Disorder] in even very young kids. Does this mean we have to put my kiddo on Ritalin?”

Go, mom. It was a great and timely question.

ADHD occurs in about 11 percent of U.S. children. Children suffering from the disorder have difficulty paying attention to the things that are most relevant in a situation (e.g., mom versus a barking dog in the background) or in controlling themselves (e.g., taking turns) compared to their peers. This ‘disorder’ may appear as some blend of these problems, and arises from how these individuals’ brains are wired to process information and manage their impulses. Families like Halley’s are looking for ways to help their children—and what may hurt them.

In October 2011, the American Academy of Pediatrics revamped and revised the decade-old guidelines for the definition, diagnosis and treatment of ADHD. The original standards addressed children aged 6-12; new guidelines include approaches on children from 4 to 18 years. As a doctor working with kids like Halley, the guidelines offer the sort of “best practices/best evidence” stuff that I wish we had more of.

We now recognize ADHD as a chronic condition that can manifest in dramatically different ways between individuals. And how it affects a particular child can change over time. Some grow out of it, or learn to work around it as they age.

To diagnose children with true attention problems or hyperactivity accurately, we must use proven tools, such as questionnaires. Clinical judgment (e.g., “I think that child looks hyper”) just isn’t enough.

Kids with ADHD-type symptoms at any age must demonstrate some degree of difficulty in various compartments of their life (i.e., not just at school or only at home). The new guidelines reinforce the need for input from family members, teachers and other care providers. These streams of information prove critical when making the diagnosis.

Increasingly, we realize ADHD often co-travels with emotional or learning problems in children. The updated guidelines provide resources and targeted questions to identify co-existing issues, such as anxiety, depression or an emerging learning disability. To be addressed properly, these issues need to be addressed in sync.

For the bigger kids with ADHD (6 and up), we healthcare providers are urged to identify the best treatment for the child and family. Parental input is key. If medications are to be considered, then the objective is to use the least amount of medication to the best advantage—ideally to minimize side effects and improve behavior.

What about Halley? For children ages 4-5 years, medication is not the first line of treatment.  Rather, research has shown that children at this age respond better when parents, educators and care providers use behavioral approaches, such as positive reinforcement, goal-setting, redirection and other techniques that help foster more resilience and adaptive skills may do the job. If we find that kids are still struggling, it may be time to consult with a specialist (say, a developmental pediatrician, neuropsychiatrist or child psychiatrist) and to explore other options.

When we did determine that Halley demonstrated some problems of inattention and impulsiveness, we did not opt to medicate. Instead, Halley’s mom is working on a game plan to redirect Halley when they see her getting wound up or dark clouds on her brow. So far, so good. We’ll see how she does—and offer help if she needs it—but staying out of her way in the meantime.

Learn More

Where Teamwork Matters: The Complicated Case of Preemies with ADHD,” LearnNow.org

What is Attention?” LearnNow.org

ADHD Seen in 11% of U.S. Children as Diagnoses Rise,” New York Times

Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)

Report Finds Training Effective for Treating Young Kids with ADHD,” U.S. Department of Health and Human Service