How do you treat ADHD?
By the faculty of Harvard Medical School for The Harvard Medical School Adviser

Q: My 4-year-old boy is very rambunctious and hard to control. Friends have suggested that he may have ADHD. Can it be diagnosed at this early age? I'm reluctant to give him medications, but what else can I do?

A: Kids like yours are often suspected of having attention-deficit/ hyperactivity disorder (ADHD). The main symptoms of the condition include hyperactivity, impulsiveness and inattentiveness. However, many normal children may have these symptoms at a low level, especially during the preschool years. And the symptoms may be caused by another disorder. That's why it's important that the child receive a thorough examination and appropriate diagnosis by a wellqualified professional.

To show that something more is involved than just kids being kids, clinicians and researchers compare a child with others the same age to determine whether the symptoms are severe, frequent, persistent and outside the range of behaviors seen in normal development.

Studies have found that ADHD symptoms under age 6 are strikingly similar to those found in older children. Depression and defiant behavior are also common. These children are not just rambunctious. They seem unable to wait their turn or think before acting. They may jump off playground slides, play with matches despite repeated warnings, climb into medicine cabinets, rush into traffic and pull down objects from the shelves of stores. They are noisy and constantly interrupt other children and adults. They can sow chaos at home or in day care.

For a diagnosis of ADHD, the American Academy of Child and Adolescent Psychiatry recommends a general psychiatric evaluation. The process also includes interviews with parents, information from teachers and monitoring of the child in several settings.

A stimulant drug, such as methylphenidate (Ritalin and others), is the standard treatment for school-age children. Theses medications are increasingly prescribed for younger children as well. An estimated 1 percent of preschool children have been given stimulants, although the Food and Drug Administration has not approved them for children under age 6.

Because of concern about long-term effects of these medications on the developing brain, there are misgivings about prescribing drugs for very young children. The most popular alternative, parent training, aims to reduce difficult behavior by changing the way parents respond to it. Parents are shown how to set appropriate limits and use moderate rewards and punishments. Parent training might be especially helpful for preschool children. Because they are still young, the children's behavior may be reshaped. If that doesn't happen, the expectation of failure becomes selffulfilling for the child, for parents and eventually for teachers and others.

In one study, behavioral parent training was combined with an effort to encourage more constructive interactions between parents and children with ADHD. Children ages 4 to 6 who received this treatment for two months had a better outcome than those who received only general counseling. The training was about as effective as methylphenidate. But it worked only when conducted by specialists with experience in behavior therapy. And we don't know how long the improvement lasts.

ADHD has always been a controversial diagnosis. Critics believe that the diagnosis is overused and drugs are oversold as a solution. The growth of preschool programs and day care might be making excessive demands on young children for self-control and obedience to rules. But others say that ADHD is not diagnosed as often as it should be. The only two studies done in pediatric clinics found that it was not identified in preschool children even when their parents were worried about the child's behavior. One study found that only 23 percent of preschool children with possible ADHD had been referred for mental-health evaluation.

Given the doubts and disputes, it is probably best to follow the recommendations of the American Academy of Child and Adolescent Psychiatry. Make the diagnosis slowly, they advise. And consider parent training and specialized day care before resorting to stimulant drugs.

It's hard to raise a rambunctious child, whether or not he has ADHD. Consider getting an expert evaluation to see if your child might benefit from professional treatment, with or without medication.

Copyright 2007 the President and Fellows of Harvard Developed by Harvard Health Publications (www.health.harvard.edu). Distributed by UFS. Submit questions to harvard_ adviser@hms.harvard .edu.