Treatment of Attention-Deficit/Hyperactivity Disorder in Preschool-Age Children: Child and Adolescent Psychiatrists' Adherence to Clinical Practice Guidelines

By Chung, Jaeah; Tchaconas, Alexis et al. | Journal of Child and Adolescent Psychopharmacology, May 1, 2016 | Go to article overview

Treatment of Attention-Deficit/Hyperactivity Disorder in Preschool-Age Children: Child and Adolescent Psychiatrists' Adherence to Clinical Practice Guidelines


Chung, Jaeah, Tchaconas, Alexis, Meryash, David, Adesman, Andrew, Journal of Child and Adolescent Psychopharmacology


[Author Affiliation]

Jaeah Chung. 1 Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, New York.

Alexis Tchaconas. 2 Department of Pediatrics, Cohen Children's Medical Center of New York, Lake Success, New York.

David Meryash. 2 Department of Pediatrics, Cohen Children's Medical Center of New York, Lake Success, New York. 3 Department of Pediatrics, Hofstra Northwell School of Medicine, Hempstead, New York.

Andrew Adesman. 2 Department of Pediatrics, Cohen Children's Medical Center of New York, Lake Success, New York. 3 Department of Pediatrics, Hofstra Northwell School of Medicine, Hempstead, New York.

Address correspondence to: Andrew Adesman, MD, Developmental and Behavioral Pediatrics, Cohen Children's Medical Center of New York, 1983 Marcus Avenue, Suite #130, New Hyde Park, NY 11042, E-mail: AAdesman@northwell.edu

Introduction

The prevalence of attention-deficit/hyperactivity disorder (ADHD) in preschool-age children is estimated to be between 1% and 6% (Wichstrom et al. 2012). By definition, ADHD results in functional impairment in school or home/social settings (Lahey et al. 1998; Dreyer 2006). Parents of preschool children with ADHD report higher parenting-related stress (DeWolfe et al. 2000). Despite a growing awareness of ADHD in preschoolers, there had not been specific guidelines for the treatment of ADHD in this population until recently. This was due, in part, to limited empirical evidence (Kollins et al. 2006; Kaplan et al. 2011). In 1997, the American Academy of Child and Adolescent Psychiatry (AACAP) issued practice parameters for the diagnosis and treatment of ADHD--for preschoolers with ADHD, a trial of parent training and placement in a highly structured, well-staffed preschool program was recommended before initiating medication (Dulcan et al. 1997). In 2007, the AACAP published a treatment algorithm specifically for preschoolers with ADHD (Gleason et al. 2007). This algorithm indicated that parent management training or other behavior interventions should be attempted for a minimum of 8 weeks before a pharmacological agent is used. The AACAP also recommended that, when behavior therapy failed, stimulant medication could be used, with methylphenidate (MPH) as the preferred first-line treatment.

The AACAP's recommendation to use MPH as the first-line stimulant treatment for ADHD is based on findings from a large multicenter clinical trial. The Preschool ADHD Treatment Study (PATS), funded by the National Institute of Mental Health, was the first randomized clinical trial to evaluate MPH use in preschoolers with ADHD (Kratochvil et al. 2004; Greenhill et al. 2006). The PATS was designed to address systematically the efficacy and safety of immediate-release MPH (Kaplan et al. 2011). Subjects were boys and girls 3-5 ½ years of age who met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) (American Psychiatric Association 1994) criteria for ADHD. MPH doses used in the study ranged from 1.25 mg thrice daily titrated up to a final dose of 7.5 mg thrice daily. Medication efficacy was measured using teacher and parent versions of the Swanson, Nolan, and Pelham Rating Scale. The study demonstrated significant reductions of ADHD symptoms in preschool children compared with placebo, although effect sizes (0.4-0.8) were smaller than those cited for school-age children treated with MPH (Greenhill et al. 2006).

Although ADHD treatment guidelines are now available for preschool children, to date no studies have examined to what extent child and adolescent psychiatrists (CAPs) follow these guidelines regarding initiation of pharmacotherapy. Similarly, there is no information about what factors influence a clinician's decision to initiate treatment with medication in young children with ADHD.

Methods

This study was reviewed and approved by the Institutional Review Board of the North Shore-Long Island Jewish Health System. …

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