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Ped Med: ADHD in the very young

Feb 16, 2006 | UPI

Discerning behavior that portends attention-deficit/hyperactivity disorder presents challenges during the highly volatile first years of life.

"The range of symptoms is greatest in the youngest children: there is more impulsivity, low frustration tolerance, aggression than in older children," said ADHD investigator Donna Palumbo of the University of Rochester in New York. "It's much harder to diagnose preschoolers."

Because the diagnostic criteria call for symptoms that set the child back in at least two social settings, most youngsters do not qualify until they enter school, daycare, or some other arena that requires an engagement with their peers.

"We wouldn't interfere with infants or toddlers unless their behavior interfered with functioning, for example, if they were really aggressive," Palumbo said. "Most can do fine until they're around other children."

In her practice, Palumbo conducts behavior modification with parents, providing them with tools to deal with their child's disruptive deportment, before resorting to medication.

One of the theories she is testing in her investigation of 500 preschoolers is that such intervention with mom and dad might postpone, or even eliminate, the need to medicate the child.

A growing number of critics take issue with what they see as a tendency to over-prescribe potentially risky medications to children, particulary in view of the dearth of scientific evidence of the long-term effects of the drugs on developing bodies and brains.

The medicating of preschool minds comes under particularly harsh attack. Among the concerns is that this demographic, more than any other, has a wildly inconsistent response to the treatment.

A review of studies of 3-to-6-year-olds with ADHD, published in the Journal of Developmental and Behavioral Pediatrics, for example, shows this age group is more likely than its elders to experience a wide array of responses to and side effects from the stimulant drugs that comprise the single most popular first-line treatment of the disorder.

Keeping close tabs on any side effects is important, especially in view of a recent preliminary Food and Drug Administration report that drew a tentative link between stimulants and sudden deaths, strokes, heart attacks, high blood pressure and other serious complications in a small number of users, including children, although none was younger than 7.

Researchers stressed the results were tentative and theoretical. The review did not determine whether all the patients were actually taking the ADHD medicines at the time or account for such confounding factors as preexisting health conditions. However, the regulators considered the risk high enough to warrant immediate monitoring and further study.

Overall, 25 sudden deaths, including 19 in children ages 7 to 16, and 54 cases of serious, though not fatal, cardiovascular or cerebrovascular adverse events, 26 of them in minors under 18, occurred in patients taking the drugs between 1999 and 2003, according to the report. Those who died included 11 children treated with Adderall, one with Adderall XR, three with Ritalin, and four with Concerta, the study showed.

What role, if any, the drugs played is difficult to assess because some of the youngsters had underlying heart conditions that could have contributed to their demise, the report concluded.

Although the authors stressed no final conclusions about stimulant safety could be drawn from the analysis released Feb. 8, the following day an FDA panel took the highly unorthodox step of veering off its assigned course to call for strong new warnings on the drugs' labels and in their advertisements.

As time goes by, even when untreated, some of the symptoms of ADHD seen at younger ages tend to dampen, though not disappear, scientists said.

"The frontal lobe of the brain, which controls these behaviors, matures until age 21," Palumbo explained. "As children mature, some symptoms get better though they don't grow out of ADHD, as used to be believed, and half need treatment into adulthood."

Research has shown, in fact, the behavioral shift over the early years can be sufficiently profound to alter an initial diagnosis.

In a study of 118 tots ages 4 to 6, the investigators observed in some cases the symptomatic comportment took so many twists and turns over the eight-year study period, it detoured from the original classification, falling into another category of the disorder or even out of the ADHD realm altogether.

"Was (hyperactivity/impulsivity) 'outgrown,' suggesting that it is only a transient problem that may not require treatment, or did (these) children shift to (another ADHD category)?" the study authors wondered. Their qualified answer: "Both."

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