The Checkup
By PERRI KLASS, M.D.

Preschool children are supposed to run around a lot and jump from one activity to the next. Trying to decide whether a 4-year-old’s activity level or attention span is truly problematic can raise a challenging mix of questions and concerns about children being medicated for behaving, well, like children.

In 2011, when the American Academy of Pediatrics began including preschoolers in its guidelines for diagnosing and treating attention deficit hyperactivity disorder, some media reports blasted the idea. Were we planning to medicate toddlers? Would A.D.H.D. diagnoses surge once pediatricians started looking for it in preschoolers?

On the other hand, thinking about attention deficit problems at a very young age can help those children who are really struggling academically and socially. And notably, the recommendation for first line treatment for an A.D.H.D. diagnosis in a preschooler is behavioral therapy, not drugs.

A study published recently in the journal Pediatrics found that including preschoolers in the guidelines for how pediatricians manage A.D.H.D. — which covered only school-age children before 2011 — did not increase diagnoses and prescriptions of stimulant medications; in fact, the diagnoses, which had been on the rise, leveled off.

When the guidelines were released, “we got criticized in the popular press that we were now drugging children,” recalled Dr. Mark Wolraich, the section chief of developmental behavioral pediatrics at the University of Oklahoma Health Sciences Center, who was the first author on the 2011 guidelines.

In fact, he said, before the guidelines appeared, many preschool children were being treated with medication for their short attention spans and their high activity levels; what the guidelines actually did was recommend that instead, behavioral therapy should be the initial recourse for children in this age group.

In the new study, researchers looked at electronic health records of children from 63 different pediatric practices. Before the guidelines, the rate of A.D.H.D. diagnosis in preschoolers was increasing, said Dr. Alexander G. Fiks, a pediatrician who is a faculty member at the Children’s Hospital of Philadelphia and the lead author of the study.

But after the guidelines were issued, the rate of diagnosis stopped increasing, while prescriptions for stimulant medications stayed the same — suggesting that including a category for preschool A.D.H.D. had not led pediatricians to lower their thresholds for medicating young children.

“There was no difference seen for stimulant medication prescribing before and after, it was absolutely flat,” said Dr. Fiks, director of the Pediatric Research in Office Settings Network at the American Academy of Pediatrics, which coordinated the study.

When very young children have symptoms of A.D.H.D., they may be expelled from preschool and rejected by their peers, said Dr. Nathan Blum, the chief of the division of developmental and behavioral pediatrics at the Children’s Hospital of Philadelphia.

“The kids are starting to feel that they’re not liked, that they’re bad, other kids are being turned off by them because they can’t pay attention or because they’re impulsive, can’t wait their turn,” he said.

Sometimes the child is in the wrong setting, in a preschool that is too rigidly programmed or just a bad fit. And the child also needs to be carefully evaluated for other problems that may look a lot like inattention, ranging from autism spectrum disorder to sleep problems to stress and trauma.

“Parents of preschoolers who are struggling with behavior problems should talk to their pediatricians,” Dr. Fiks said. “Many of these kids will have variations of normal behavior.” Some children will have A.D.H.D. and others will have other social, medical, developmental or psychological problems.

That’s another good argument for first-line behavioral therapy, which helps parents deal more effectively with the problematic behavior, whether or not there’s a formal diagnosis of A.D.H.D.; the same techniques can be applied in preschool training. The troubling news about these children is that many of them are not actually getting that recommended behavioral therapy, and some of the families who think they are getting it may not be getting the kind of therapy that has actually been shown to be effective.

The evidence suggests that what works is not therapy that focuses on the child — such as play therapy — but coaching and training for the parents. That does not mean that the parents were the problem in the first place, it means that the parents have been dealt a particularly difficult assignment, and the standard strategies that the rest of us use with our children are not going to be sufficient.

But many parents feel blamed and judged for their children’s problem behavior, Dr. Blum said, and they may interpret being sent to parenting classes as still another accusation. “I think it’s really important for parents to understand they’re struggling because of their child’s behavior, but they’re still the agent of change and so we have to work with them.”

Behavioral therapy has been shown to be effective in this age group, and the medications are comparatively less effective than they are in older children, and somewhat more likely to cause side effects. So there’s a general sense that even though A.D.H.D. is a chronic condition and some children will need medication later on, it’s better, when possible, to delay starting it and use the behavioral therapy first.

In one study that looked at the use of Ritalin in preschool children with a diagnosis of A.D.H.D., Dr. Wolraich said, all the families were required to go through parent training before any were given medication. A third of the children required no further therapy, and thus were not enrolled in the medication study.

“If your child does have A.D.H.D., then you have to be a lot more consistent than most parents need to be in managing your child,” Dr. Wolraich said. “Having a coach is really helping to empower the parents to be more effective.”