Brain functioning is genetically variable (polymorphic) and has plasticity – adaptability to conditions and experience.  When you learn a new skill  or habit – at any age  (though easier when in childhood) it changes your brain.  Neurons establish new connections.  Connections are strengthened – more receptors and nerve impulses are made faster and more myelin (insulation) is enhanced. 

Now new research is showing that giving more structure to a preschooler’s day can improve ADHD symptoms.  A recent study of treating preschoolers with medication found that the medication did help but not as much as in older kids and with more side-effects – leading to the conclusion that the need and potential benefits have to be greater in younger kids to justify use. 

Having behavioral alternatives is much more acceptable to most parents who worry that medication may not be the right answer.

I know you’re thinking, why not do the same thing with school age kids?  Probably the most elaborate research study in psychiatry ever was the MTA study.  Medication was unequivocally the superior treatment for school age children. 

MTA link:  www.askdrjones.com/

Although I don’t treat a lot of preschoolers I have treated a few and I generally recommend medication with the following conditions:

1.    If I don’t treat the kid’s ADHD I’m going to have to treat the parents and siblings for major stress symptoms

2.    If I don’t treat the kid no day care will keep them and mother (frequently a single parent) or father won’t be able to work and they’ll be standing in soup lines and bunking down at the Salvation Army

3.    Extreme impulsivity resulting in dangerous behavior like running out in the street

Ironically, methylphenidate has been the most studied in preschoolers but only dextroamphetamine is approved down to age three.

Estimates of incidence of significant ADHD symptoms in preschoolers are 1 to 4%.  The best test is to be in a room with them for a while – how bad do you need a drink or a Xanax afterwards?  The second best test is how much does mother look like the “before pictures” of the woman in the mattress commercials?  (Or in the case of the one with Lindsay Wagner even the after picture looks pretty haggard.)

A five year old study sponsored by the National Institute of Mental Health provided a range of behavioral therapies to135 preschool kids with severe ADHD:

1.    Families were given parent education classes only

2.    Or classes and home visits by researchers who gave individualized behavioral therapy for each child’s particular needs

After one year aggressive behavior and learning had improved by 30%.  One parent said the most effective technique was providing predictability, such as, we are going to be leaving the playground in 5 minutes, 4 minutes, etc.  (She didn’t mention having to use a lasso or pepper spray when it was time to actually leave).  She also thought it was helpful to praise the child for doing things like behaving during a boring activity, helping with cleanup, or other positive behaviors.  (This study was reported in School Psychology Review Sept 07).

Classic behavioral management principles of parenting are:

1.    Behavior you like and want more of (praise, reward)

2.    Behavior you don’t like but that doesn’t bother you or others particularly (so you ignore)

3.    Behavior you can’t stand or is bothering others (punish) 

Note: Time-outs work well.  They provide the first opportunity to use the power of the “pop” (e.g., when they refuse to go to time-out).

The problem is that classic parenting doesn’t always work so great.  As Dennis the Menace said in one cartoon, “by the time I realize the consequences of my action I’ve already done it”.     www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

A study of 3,000 randomly selected kids ages 8-15 was funded by the National Institute of Health (with no pharmaceutical company support).  The main author was Tanya Froehlich, a developmental behavior pediatrician.   The study was published in Archives of Pediatric & Adolescent Medicine Sept 07.

Originally the objective was to see if ADHD in kids was being over diagnosed and over treated.  Actual findings showed only 3% of those without ADHD were receiving medical treatment – and they could have represented kids who had improved so no longer met criteria.  They also found that 9% of the 3,000 kids had ADHD of which only 1/3 were consistently being treated.

That finding or worse has been repeatedly found – the question is, WHY?

I believe the most common reason is that the patient has not taken “the right medication at the right dose”.

 In consulting with physicians in their offices a frequently mentioned problem is getting kids to take their meds.  My approach is to first redefine the problem for kids and their families.

ADHD is a type of personality that makes it difficult to focus on things that aren’t interesting.

Like what?  Like school mostly.  The cause is genetic (polymorphism).  Mother Nature doesn’t want ADHD kids or adults spending time with boring, repetitive stuff.  ADHD people are the explorers, challengers, and changers of the world.

One of the problems with being ADHD is that in order for us to go to the best schools and get the best jobs, starting with the 9th grade we need to perform well in school and keep up with boring details (and at work boring reports, etc.)

The GOOD news is that medication – especially stimulants make our lives better by giving us the ability to do well on the boring stuff.  It also helps us stay calm and still when appropriate, and in control.

THE GOAL

The goal is to find a medication that kids, teens, and adults like.  Their lives are easier – they’re getting things done effectively and side-effects from the meds if any, are minimal.  HINT:  The medication probably isn’t Strattera.

If medication makes kids feel bad they shouldn’t take it.  I worry more about kids/teens who take meds that make them feel bad or detached or flat or racy.  I worry about parents who keep giving kids the wrong medication or the wrong dose.

Another reason for poor consistent compliance with treatment is that usually at least one of the parents is also ADHD.  Only 10% of ADHD adults are being treated.  So the parents forget, lose the med, are running late, or don’t have time.  They can’t stay organized to keep up with getting refills, scheduling and keeping follow-up appointments, much less filing insurance forms, etc.

Again this year at the American Psychiatric Association annual meeting a group of loud marchers picketed the main conference center.  “Stop poisoning our children” and other banners were being waved.  They were mostly Scientologists who are a blend of idiocy and nuttiness.  They should be sentenced for life to be locked up with a hyperactive kid like our son was in childhood.

Unfortunately, some patients give up too quickly on one or more meds because they don’t understand all the nuances of dosing and side-effects.  But, fortunately, we keep getting better and better medications that are more effective and last all day and are safer with less side-effects.

 Newest med:www.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/