Recent practice guideline from the American Academy of Pediatrics now include a recommendation for assessment and intervention for ADHD before they begin elementary school, but many clinicians are unsure about exactly what treatment to recommend. A recent paper sponsored by the US Agency for Healthcare Research and Quality and published in the the journal JAMA Pediatrics attempts to perform a meta-analysis of ADHD treatment studies in preschoolers in order to provide a more specific evidence base. Stimulants are not approved for children below the age of 6, although medication treatment of preschool age children is not uncommon.
The authors identified treatment studies of children with disruptive behavior symptoms below the age of 6. The overall strength of evidence was rated as good, moderate, low, or insufficient based on previously published guidelines that incorporated many aspects of the studies that assessed that intervention. While the study authors had planned to provide quantitative analyses of multiple types of treatment, only Parent Behavioral Training (PBT) had enough studies to allow for the use of meta-analysis techniques while methylphenidate treatment and combined home and school/day care interventions needed to be summarized descriptively. A total of 55 studies were found (34 for parent behavioral training and 15 for pharmacotherapy).
Parent behavioral training studies were found to result in a moderate effect size that favored its use. These studies showed improvement in child disruptive behavior, ADHD symptoms, and parental skill. With regard to medication, only the Preschool ADHD Treatment Study (PATS) was deemed to be of “high” quality. The lack of additional high quality studies and amount of adverse effects with medications thus caused the overall recommendation for methylphenidate use to be low. Studies that combined PBT with school or daycare based interventions were found too conflicting to make an overall conclusion.
Based on their review of the data, the authors concluded that the research evidence suggest that parent behavioral training should be considered first line treatment for preschool ADHD.
For those less familiar with PBT, the goal of parent behavioral training is to teach parents strategies that help them manage their child’s challenging behaviors through promotion of a positive behavior and employing rewards and punishments for negative behavior. Unlike other types of child therapy, PBT tends to be quite structured and, as the name suggests, focused quite a bit on the parents. Many of these programs have individual names (Incredible Years, Parent-Child Interaction Therapy) and manuals but utilize a similar overall framework. In this study, no particular program was found to be clinically superior.
The authors acknowledged that many of the parent behavioral training studies have some methodological limitations with a sizable proportion of eligible parents not completing the course of treatment. It is also worth noting that others might quibble with their determination that only one pharmacological study is worthy of a high quality rating.
Nonetheless, it seems quite reasonable in my view to follow the recommendation that parent behavioral training be tried first for preschoolers with ADHD and other types of disruptive behavior. Finding it can be a challenge, and it may be worthwhile for clinicians to ask about it specifically or encourage parents to ask potential therapists about their experience with these techniques.
Charach et al., Interventions for preschool children at high risk for ADHD: A comparative effectiveness review. Pediatrics; 2013;131:e1584–e1604