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Parents should look towards behavioural interventions, not medication, as the first step in treating preschoolers at risk of attention deficit hyperactivity disorder, says new research from the University of Toronto, the Hospital for Sick Children and McMaster University.

In a systemic review led by University of Toronto psychiatry professor Alice Charach, head of the neuropsychiatry team at The Hospital for Sick Children (SickKids), researchers examined the effectiveness of pharmacological and behavioural treatment interventions for preschoolers at risk for ADHD and the long-term outcomes of these interventions in people of all ages. The research team includes investigators from SickKids and the McMaster University Evidence-based Practice Center. The review is available.

The findings reveal that while current ADHD medications are generally safe and effective in children, there appears to be more adverse effects in preschoolers than in older kids. For this reason, the review recommends the use of parent-led behavioural interventions as a first course of action, prior to considering medication for preschoolers at risk of ADHD.

ADHD is characterized by inattention, overactivity and impulsiveness. It is difficult to diagnose preschoolers with ADHD, because at this young age children are still maturing, and often exhibit rambunctious and active behaviour that could be confused with ADHD.

“Research supports the use of behavioural interventions as the first line of treatment for this very reason,” said Charach, principal author of the review and associate scientist at SickKids. “ADHD symptoms are clinically significant when they interfere with academic and behavioural functioning.  Parent behaviour training has proven to be highly effective in improving child behavior whether or not the child has ADHD.” 

The review found that medication is effective in controlling ADHD symptoms for a duration of 12 to 24 months in children age six and up, but because research on medication use is inconsistent after this initial treatment period, there is a lack of evidence about the long-term effects. Common side-effects include poor appetite, insomnia, headaches, stomach aches, increased blood pressure and heart rate.

“For preschoolers, essentially nothing is known about the possible long-term effects of treatment with such medications,” said Charach. “In young children these medications can cause additional irritability, moodiness and with prolonged use can also impact growth.”

Parent behaviour training is designed to promote positive parent-child relationships by helping parents manage their child’s problem behaviour with more effective discipline strategies using rewards and non-punitive consequences. The review confirmed that this type of intervention not only improves the child’s behavior but also parents’ confidence in their own parenting skills.

Furthermore, the review examined the variability in prevalence, diagnosis and treatment of ADHD. It found that more boys are diagnosed than girls, and children between the ages of five and 10 show the highest prevalence. Medication use is more common in boys than girls, in whites than Hispanics or African-Americans, in children living in high-income than low-income communities and in urban than rural.    

“The main take-away from this review is that the first intervention for preschoolers at risk of ADHD is parent behaviour training. Other interventions, like medication, may also be effective but more research is needed before definitive recommendations can be made.” 

The review was prepared for the Effective Health Care Program run by the Agency for Healthcare Research and Quality (AHRQ) in the United States. The purpose of the review is to help health-care providers make informed decisions about patient treatment and therefore improve the quality of health-care services. This comprehensive review included the detailed examination of 223 carefully selected peer-reviewed journal articles.