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: test.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”. test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/
