Given the short- and long-term safety concerns and lack of information about effect of psychopharmacological interventions on brain development of preschoolers, there is a strong clinical consensus that psychosocial interventions should be tried first in preschoolers with ADHD (Dulcan and Benson 1997
; Gleason et al. 2007
; Kollins et al. 2006
). A psychosocial intervention plan should address child's behavior problems both at home and at school. Parent behavior training should be offered to the caregivers, and parents should be encouraged to work with their child's preschool or daycare teacher to integrate coordinated behavior management strategies at home and at preschool or daycare. Direct child training in the classroom can be implemented as indicated. Comorbid disorders should be identified and appropriate work-up and interventions (e.g., speech, language, and communication assessment and treatment for preschoolers presenting with language delays) should be included in the treatment plan. It is important to assess and support treatment and social support needs of the caregivers. If the caregivers believe that their child's behavioral symptoms become worse with food additives and/or certain foods, a careful trial of additive free and/or the restricted diet can be implemented under the supervision of a nutritionist and the child's pediatrician, as described previously.
Pharmacological intervention can be considered when psychosocial intervention has been unsuccessful (Dulcan and Benson 1997
) or only partially successful. Care and caution should be exercised in selecting medication dosage for preschool children. Practitioners need to consider the unique sensitivity of preschool children to adverse events and should follow the rule of “start low, go slow” allowing sufficient time on a particular dose to estimate adverse effects and efficacy. At the same time care should be taken to avoid undertreatment with lower doses. Preschoolers should be followed closely for monitoring of possible emergence of adverse effects and dosage adjustment with weekly or biweekly (every other week) visits for the first 1–2 months and then monthly for maintenance visits once the preschooler is on an optimal dose.
Parent and teacher rating scales (e.g., CRS, SNAP, CBCL-1½, ADHD-RS) should be collected for baseline behaviors and repeated regularly for ongoing monitoring of treatment response during follow-up visits.
As mentioned previously, MPH has the best evidence (Greenhill et al. 2006
) and is most frequently started at 2.5
mg BID and increased to 7.5
mg BID or TID over the course of 2–4 weeks depending on the child's response and any side effects. It is important to note that there are a minority of preschoolers who may benefit from 1.25
mg TID of MPH; 15% of the preschoolers in the PATS were reported to be best responding to 1.25
mg TID, and teachers reported improved ADHD symptoms with 1.25
mg TID compared to placebo (Greenhill et al. 2006
Decision for a BID or TID dose may be based on the child's and family's needs. For example, some parents want their preschooler to take medication only when the child attends school and hence may prefer BID dose instead of the TID dose used in the PATS (Greenhill et al. 2006
There are no controlled efficacy data for long acting MPH or other psychostimulants or non-stimulants in preschoolers with ADHD. If a preschooler does not respond to MPH, clinicians are left to extrapolate data from older school-age children. Based on school-age ADHD treatment data, if a child does not respond to a trial of one class of stimulants (e.g., MPH), switching to the other class (e.g., amphetamines) is recommended before using another drug class (Arnold et al. 1978
; Dulcan and Benson 1997
; Elia et al. 1991
). There are no empirical data to guide dosing schedules for amphetamines in preschoolers with ADHD; it has been suggested that amphetamines are twice as potent as MPH (Pelham et al. 1999
). If a preschooler does not respond to stimulants and/or has unacceptable side effects, a trial of atomoxetine or alpha-agonists is recommended (Gleason et al. 2007
). As mentioned previously, there are no controlled efficacy or dose response data for atomoxetine or alpha-agonists in preschoolers with ADHD. Improvement in ADHD symptoms in 22, 5- and 6-year-old children (mean age 6.1
0.58 years) was reported in a prospective open-label trial with 10–40
mg/day or 0.47–1.88
mg/kg/day of atomoxetine (mean dose
mg/kg/day) administered as a single morning dose or BID (morning and afternoon) (Kratochvil et al. 2007
). Adverse effects included mood lability in 54.5% and decreased appetite in 50% of the children. Regarding alpha-agonists, there are only 2 case reports of open-label treatment with clonidine (0.025
mg TID) and guanfacine (0.25
mg BID to 0.5
mg BID) both reporting improvement in ADHD symptoms and side effect of sedation early in treatment.
The limited evidence for efficacious treatment options relative to the frequency with which preschool children are referred for treatment of ADHD is striking. Additionally, it is noteworthy that as noted earlier, nonpharmacological treatment investigations lag behind pharmacological treatment studies in preschoolers formally diagnosed with ADHD. This is especially salient since there are short- and long-term safety concerns and there is little information regarding the effect of pharmacological agents on the brain development of preschool children with ADHD. Because of the fewer safety concerns compared to pharmacological treatments, clinicians, caregivers of preschoolers with ADHD, professional organizations making treatment recommendations, and the community at large prefer psychosocial interventions as a first line of treatment for preschool ADHD. This calls for more research to find the best possible treatments matched with parent preferences in order to expand the limited intervention options that are currently available for treating ADHD in preschoolers. There is an urgent need for well-designed, blind, randomized, controlled, between-group treatment trials to study comparative and combined efficacy and safety of psychopharmacological, psychosocial and alternative treatments in well characterized samples of preschool children with ADHD. It is important to study the long-term outcome and safety of treatment interventions and their impact on the developing brain of preschool children with ADHD.