ADHD Evals for Preschoolers: New Guidelines Stir Overdiagnosis Fears

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The American Academy of Pediatrics expanded its guidelines regarding attention-deficit hyperactivity disorder this weekend, recommending that pediatricians start evaluations as early as preschool and continue them through high school

Previous guidelines, developed more than a decade ago, targeted kids between the ages of 6 and 12, but mounting evidence suggests that it's possible to diagnose and treat the disorder starting at age 4 and as late as age 18, according to a report on ADHD released Sunday.

The verifiable explosion of ADHD diagnoses in the past decade has fanned fears over the potential to overdiagnosis it. According to the Academy of Pediatrics, anywhere from 4 to 12 percent of school-age kids are diagnosed with ADHD, and in many cases, are prescribed stimulants such as Ritalin and Adderall as the first-line approach to treatment.

Broadening the age group for evaluation fans fears that ADHD coud be overdiagnosed and kids overmedicated.

A September survey published in the American Journal of Psychiatry found that the use of stimulant medication to treat ADHD had risen in the past 15 years, with the number of kids between the ages of 13 and 18 on meds rising 6.5 percent each year since 1996.

An informal online survey by Medpage Today a week before the new guidelines were released found that nearly 80 percent of the 1,500 people surveyed believed that ADHD was overdiagnosed.

"As someone who works on medication authorizations on a daily basis, I see more kids under the age of 12 receiving insane doses of ADHD meds or antidepressants, even exceeding safe FDA recommended guidelines," one MedPage Today reader said. He added that many of these children do not have documented neurological deficits, but their medical charts note that either the parents or the school requested evaluation for ADHD.

Doctors specializing in ADHD note that the guidelines, if followed correctly, may not bring the increased medication that some fear.

"The guidelines reflect what is already happening, that doctors are seeing and treating ADHD younger," says Dr. Michael Coates, chairman of family medicine at Wake Forest University. "My feeling is that if someone adheres to these guidelines for diagnosis, they would diagnose less – that's been the issue. People just see a hyperactive kid and put them on a pill," he says. Without guidelines like these that lay out the diagnostic criteria for what is actually ADHD, he says, "I would worry about looser reins on how you make diagnoses and give out medicine."

Even though the guidelines open up treatment to preschoolers and even to those who do not meet the full criteria for full-blown ADHD, the American Academy of Pediatrics is recommending behavioral interventions administered by parents, teachers, or mental health professionals to these patients, not medication.

"This issue of overdiagnosing has people in a tither because many believe that if we diagnose we will automatically treat with medicine. That is not the case, and in fact the guidelines suggest using behavioral methods first in young children, not medicine," says Dr. Michael Manos head of the Center for Behavioral Health at the Cleveland Clinic.

"The new guidelines are based on the wealth of scientific information generated in ADHD over the last two decades," he says. "The guidelines extend the age of diagnosis of ADHD primarily so we can make a difference where it is most needed -- before school formally starts and before college and the work force."

In line with several studies published since the 2000 guidelines were published, the new recommendations that support prescribint medication to kids 6 and olderr suggest that medication be the first and potentially only intervention among patients 12 and over, even though behavioral intervention is a preferable but not required complement to stimulant drugs.

It boils down to how the guidelines are used, says Dr. William Pelham, director of the Center for Children and Families at the State University of New York at Buffalo.

"I personally disagree with, and the long-term data do not support, using medication as the first line treatment. If every child who gets diagnosed automatically gets medication, I would be upset with diagnostic standards that identify more children," he says. "On the other hand, if identification meant better training for parents, kids and teachers in behavioral interventions, I would be pleased at increased diagnostic prevalence."