Psychosocial treatments for preschool-aged children with Attention-Deficit Hyperactivity Disorder

Diagnosis and Treatment Options for Preschoolers with Attention-Deficit/Hyperactivity Disorder

Objective: The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), classifies attention-deficit/hyperactivity disorder (ADHD) as a neurodevelopmental disorder, with symptoms becoming apparent as early as the preschool years. Early recognition can lead to interventions such as parent/teacher-administered behavior therapy, the recommended first-line treatment for preschool patients. There are few data, however, to inform the use of second-line, pharmacotherapy options in this population. In this review, we identified recent literature on the diagnosis and treatment of ADHD in preschool children. Methods: A PubMed and clinicaltrials.gov search was conducted for trials assessing efficacy or safety of ADHD medications in children aged <6 years. Diagnostic methods and criteria focusing on recognition of ADHD in preschool children were also surveyed. Results: The DSM-5 describes different manifestations of ADHD in preschool versus school-aged children, but does not list separate criteria by age group. Importantly, behaviors indicative of ADHD in older children may be developmentally appropriate in preschool children. Several behavioral rating scales have been validated in children younger than 6 years of age for assessing ADHD. The Preschool ADHD Treatment Study (PATS) has provided the most extensive efficacy and safety data on methylphenidate (MPH) for ADHD in preschoolers to date, with significant improvement in ADHD symptoms observed with MPH compared with placebo, although adverse event-related discontinuation was higher in PATS compared with studies of MPH for ADHD in school-aged children. Since PATS was conducted, few studies designed to assess ADHD medication effectiveness in preschool children have been published. One article reported significant improvement in ADHD symptoms with MPH (immediate release) versus placebo, two studies showed no difference between MPH and risperidone or MPH plus risperidone in relief of ADHD symptoms, and one study demonstrated the efficacy of atomoxetine versus placebo for ADHD symptoms in preschoolers. Conclusions: Further research is needed on pharmacotherapy for preschool children with ADHD.

Preschool children's response to behavioural parent training and parental predictors of outcome in routine clinical care

OBJECTIVE

To investigate the effectiveness of behavioral parent training (BPT) for preschool children with disruptive behaviours and to explore parental predictors of response.

METHODS

Parents of 68 preschool children, aged between 2.7 and 5.9 years, participated in BPT. We evaluated the changes in children's behaviour after BPT with a one group pretest-posttest design, using a waiting period for a double pretest. Outcome was based on parents' reports of the intensity and number of behaviour problems on the Eyberg Child Behavior Inventory. Predictor variables included parents' attention-deficit/hyperactivity disorder symptoms, antisocial behaviours, and alcohol use, and maternal parenting self-efficacy and disciplining.

RESULTS

Mother-reported child behaviour problems did not change in the waiting period but improved significantly after BPT (d = 0.63). High levels of alcohol use by fathers and low levels of maternal ineffective disciplining were each associated with somewhat worse outcome.

CONCLUSIONS

BPT under routine care conditions clearly improves disruptive behaviours in preschool children. Mothers who consider themselves as inadequate in disciplining and mothers whose partners do not consume high levels of alcohol report the largest improvements.

The emergence and stability of attention deficit hyperactivity disorder in boys with fragile X syndrome

BACKGROUND

Children with fragile X syndrome (FXS) are at high risk for developing a range of behavioural disorders, including attention deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD). However, very few studies have investigated the comorbid profile of FXS and ADHD and the possible dissociation from the FXS and ASD profile. The present study examined the relationship of childhood temperament characteristics of the Surgency facet (activity level, impulsivity, approach, shyness, and smiling and laughter) and the severity of ADHD and ASD features at two measurement time points in childhood, preschool (ages 3-4) and at school entry (ages 5-6).

METHODS

The study consisted of males with FXS measured at each time point (preschool and school entry), as well as comparison of typically developing (TD) boys at the preschool measurement time point. Parent reported measures of temperament and behavioural symptoms were collected at each time point. Multiple regression analyses were used to analyse obtained data.

RESULTS

Elevated activity level scores are associated with ADHD scores at preschool age and elevated shyness and decreased smiling and laughter are strongly associated with ADHD scores upon school entry. Impulsivity emerges as a strong indicator of elevated ADHD scores around school age, but even preschool impulsivity scores demonstrate some predictive value for higher ADHD scores later in school. Finally, no Surgency characteristic was significantly related to ASD scores at any age.

CONCLUSIONS

Impulsivity serves as an indicator of elevated ADHD symptoms across development periods in boys with FXS, while activity level is just indicative of higher ADHD scores at the preschool age. The Surgency facet of temperament at either age does not predict strong relationships of comorbid pathologies of ADHD and ASD in FXS. However, Surgency characteristics may serve as informative discriminative factors when studying behavioural outcomes in boys with FXS.

Mental Disorders in Early Childhood

BACKGROUND

About 17% of all children suffer from a mental disorder in early childhood, defined as the period up to the age of 6 years.

METHODS

This review is based on publications retrieved by a selective search in PubMed and the Web of Science, as well as on the authors' clinical and scientific experience.

RESULTS

In children up to age 2, disorders of emotional and motor regulation are common (ca. 7%), as are feeding problems (25%), which persist in 2% of children to meet the diagnostic criteria for a feeding disorder. Reactive attachment disorder, a serious mental illness, has a prevalence of about 1%: it is more common among children in situations of increased risk, e.g., orphanages and foster homes. Preschool children can develop anxiety disorder and depressive disorder, as well as hyperactivity and behavioral disorders (the latter two mainly in boys). Parent training and parent-child psychotherapy have been found to be effective treatments. There is no evidence that psychotropic drugs are effective in early childhood.

CONCLUSION

The diagnostician should act cautiously when assigning psychopathological significance to symptoms arising in early childhood but should still be able to recognize mental disorders early from the way they are embedded in the child's interactive relationships with parents or significant others, and then to initiate the appropriate treatment. Psychotherapy in this age group is still in need of validation by efficacy studies and longitudinal studies of adequate quality.

Effectiveness of a Cognitive–Functional Group Intervention Among Preschoolers With Attention Deficit Hyperactivity Disorder: A Pilot Study

OBJECTIVE. To test functional improvement after a group cognitive–functional occupational therapy intervention for preschoolers with attention deficit hyperactivity disorder (ADHD).

METHOD. Seventeen preschooler–parent dyads attended 11 weekly group sessions focused on acquiring executive strategies through occupational performance. Functional improvement was measured using the Canadian Occupational Performance Measure (COPM) and Goal Attainment Scaling (GAS); executive function, using the Behavior Rating Inventory of Executive Function–Pediatric; ADHD symptomatology, using Conners’ Parent Rating Scale–Revised and Conners’ Teacher Rating Scale–Revised; and social functioning, using the Social Participation scale of the Sensory Processing Measure.

RESULTS. Significant improvement was found on the COPM and GAS measures, whereas mixed results were found on the other measures, with improvements found in children whose scores indicated impairment at baseline.

CONCLUSIONS. Cognitive–functional group intervention appears to significantly improve daily functioning, executive function, and social functioning for children who demonstrate clinical impairment. Further research with a larger sample, a control group, and follow-up is required.

Assessing the effectiveness of the 'Incredible Years(®) parent training' to parents of young children with ADHD symptoms - a preliminary report

This study examined the effectiveness of an evidence-based parent training program in a real-world Scandinavian setting. Parents of 36 young children with or at risk of Attention Deficit Hyperactive Disorder (ADHD) self-referred to participate in the Incredible Years(®) Parent Training Program (IYPT) through a Danish early intervention clinic. Using a benchmarking approach, we compared self-report data with data from a recent efficacy study. Eight out of nine outcome measures showed comparable or higher magnitude of effect from pretest to posttest. Effects were maintained or improved across six months. The methodology of this study exemplifies a rigorous but feasible approach to assessing effectiveness when evidence-based US protocols are transferred into the existing Scandinavian service delivery. Findings suggest that IYPT can be implemented successfully as an easy-access early intervention to families of children with or at risk of ADHD.

Behavior management for preschool-aged children

This article summarizes behavior management strategies for preschool children who are at high risk for attention-deficit/hyperactivity disorder that have found to be effective in improving child behavior. Both parent and teacher training programs are reviewed, as these have been backed by substantial research evidence. In addition, multimodal treatments that include some combination of parent training, teacher training, and social skills training are also reviewed. Interventions emphasize the need for a strong adult-child relationship combined with proactive behavior management strategies to improve child behavior.

The Efficacy of a Home-School Intervention for Preschoolers With Challenging Behaviors: A Randomized Controlled Trial of Preschool First Step to Success

The field of early intervention is currently faced with the challenge of reducing the prevalence of antisocial behavior in children. Longitudinal outcomes research indicates that increased antisocial behavior and impairments in social competence skills during the preschool years often serve as harbingers of future adjustment problems in a number of domains including mental health, interpersonal relations, and academic achievement. This article reports the results of a cross-site randomized controlled trial, in which 128 preschool children with challenging behaviors were assigned to either a Preschool First Step to Success (PFS) intervention (i.e., experimental) or a usual-care (i.e., control) group. Regression analyses indicated that children assigned to the Preschool First Step intervention had significantly higher social skills, and significantly fewer behavior problems, across a variety of teacher- and parent-reported measures at postintervention. Effect sizes for teacher-reported effects ranged from medium to large across a variety of social competency indicators; effect sizes for parent-reported social skills and problem behaviors were small to medium, respectively. These results suggest that the preschool adaptation of the First Step intervention program provides early intervention participants, staff, and professionals with a viable intervention option to address emerging antisocial behavior and externalizing behavior disorders prior to school entry.

Language profiles and mental health problems in children with specific language impairment and children with ADHD

OBJECTIVE

This study aimed to explore whether children with specific language impairment (SLI) and children with ADHD can be differentiated from each other in terms of their language profiles, and also to investigate whether these two clinical groups differ regarding mental health problems.

METHOD

A total of 59 children in the age range 6 to 12 years participated in the study. The parents completed the Children's Communication Checklist-Second Edition and the Strengths and Difficulties Questionnaire.

RESULTS

Communication impairments were as prominent in the ADHD group as in the SLI group; however, the groups were separable from each other in terms of their language profiles. Furthermore, the ADHD group experienced significantly more mental health problems compared with the SLI group.

CONCLUSION

Language should be assessed in children with ADHD and instruments sensitive to ADHD should be included when assessing children with SLI. Mental health should be an area of concern to be addressed in both groups.

Neuroimaging and ADHD: fMRI, PET, DTI findings, and methodological limitations

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by pervasive and developmentally inappropriate levels of inattention, impulsivity, and hyperactivity. There is no conclusive cause of ADHD although a number of etiologic theories have been advanced. Research across neuroanatomical, neurochemical, and genetic disciplines collectively support a physiological basis for ADHD and, within the past decade, the number of neuroimaging studies concerning ADHD has increased exponentially. The current selective review summarizes research findings concerning ADHD using functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and diffusion tensor imaging (DTI). Although these technologies and studies offer promise in helping to better understand the physiologic underpinnings of ADHD, they are not without methodological problems, including inadequate sensitivity and specificity for psychiatric disorders. Consequently, neuroimaging technology, in its current state of development, should not be used to inform clinical practice.

Interventions for preschool children at high risk for ADHD: a comparative effectiveness review

OBJECTIVES

The US Agency for Healthcare Research and Quality sponsored a comparative effectiveness review of interventions for preschoolers at risk for attention-deficit/hyperactivity disorder (ADHD).

METHODS

Medline, Cochrane CENTRAL, Embase, PsycInfo, and Education Resources Information Center were searched from 1980 to November 24, 2011. Selected studies were comparative, and enrolled children <6 years with clinically significant disruptive behavior, including ADHD. The interventions evaluated were parent behavior training (PBT), combined home and school/day care interventions, and methylphenidate use. Data were extracted by using customized software. Two independent raters evaluated studies as good, fair, or poor by using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies Risk of Bias. Overall strength of evidence (SOE) was rated for each intervention's effectiveness, accounting for study design, systematic error, consistency of results, directness of evidence, and certainty regarding outcome.

RESULTS

Fifty-five studies were examined. Only studies examining PBT interventions could be pooled statistically using meta-analysis. Eight "good" studies examined PBT, total n = 424; SOE was high for improved child behavior, standardized mean difference = -0.68 (95% confidence interval: -0.88 to -0.47), with minimal heterogeneity among studies. Only 1 good study evaluated methylphenidate, total n = 114; therefore, SOE for methylphenidate was low. Combined home and school/day care interventions showed inconsistent results. The literature reported adverse effects for methylphenidate but not for PBT.

CONCLUSIONS

With more studies consistently documenting effectiveness, PBT interventions have greater evidence of effectiveness than methylphenidate for treatment of preschoolers at risk for ADHD.

Treatment of preschoolers with attention-deficit/hyperactivity disorder

This article reviews the current treatment literature for attention-deficit/hyperactivity disorder (ADHD) in preschoolers. Parent training studies show consistent behavioral improvements reported by teachers and observers as well as parents, with evidence of clinically significant improvement in ADHD symptoms for up to 2 years. Few other behavioral interventions have been evaluated, although data from a large psychosocial, multimodal intervention are forthcoming. There is evidence to support the benefit of immediate-release stimulant medication for up to 1 year; however, effects do not seem to be as large, and some of the side effects may be greater than for school-age children. With regard to nonstimulants such as atomoxetine, there are literally no controlled outcome data for children with ADHD who are younger than 5 years of age. Overall, a great deal remains to be learned about the safety and efficacy of pharmacotherapy in this age group. Fortunately, results of several large intervention studies will be available soon to better inform clinical practice.