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G658 A review of the evidence for the diagnosis and management of pre-school ADHD

Background NICE guidelines (NG87)1 recognises the under 5 or pre-school ADHD and recommends ADHD-focused group-based parent-training programme as the first-line treatment and taking advice from a specialist ADHD service/or tertiary service if above fails. NICE also reported that there was limited evidence on the efficacy of medication, with concerns and lack of evidence about the long-term effects of medication, in terms of growth and development among pre-school ADHD children. However, NICE also commented that untreated ADHD can have far-reaching, long-lasting negative impacts on a child’s life and further specialist advice, ideally from a tertiary service should be sought if Parent-training programme and environmental modifications are not effective. The recommendations from the American Academy of Child and Adolescent Psychiatrist (AACP) and the The American Academy of pediatrics (AAP)2 are slightly different. The AAP recommends that the primary care clinician should prescribe evidence-based parent- and/or teacher-administered behavior therapy as first line treatment and may prescribe Methylphenidate if the behavior therapy does not provide significant improvement. They recommend that in areas where evidence-based behavioral therapy is not available, the clinician needs to weigh the risks of starting medication at an early age against the harm of delaying diagnosis and treatment. Methods A review of recently published literature was conducted, including meta-analyses and national guidelines. A survey of clinical experience among a cohort of ADHD specialists across the UK was also conducted. Three illustrative cases of preschool ADHD is presented to highlight the variable management approaches used. Results The literature review showed few studies on preschool ADHD from Europe/UK. A review of ‘Pre School ADHD Treatment Study (PATS)’3 on Efficacy and safety of immediate release Methylphenidate in preschool children (Greenhill et al 2006) suggested that Methylphenidate in 2.5-, 5-, and 7.5 mg doses three times daily, produced significant reductions on ADHD symptom scales compared to placebo, although effect sizes (0.4–0.8) were smaller than those cited for school-age children on the same medication. The follow up study by Vitiello et al (2015), showed about 2/3rd of participants from original PATS study were still on the medication andthe long-term pharmacotherapy of pre-schoolers with ADHD was heterogeneous. Conclusion Pre-school ADHD studies are predominantly from the USA. NICE guidelines tend to take a more conservative approach. Medication should be considered only if others measures have failed and after a tertiary specialist opinion. We need more UK/European studies to measure how prevalent is ADHD in pre-schoolers. Also in the UK, ADHD specific Parental training programmes are patchy which can encourage pharmacotherapy. More investment on ADHD specific parental intervention/Parental training programme is needed. References NICE guidelines (NG87), 20182. A review of Pre School ADHD Treatment Study (PATS) on Efficacy and safety of IR Methylphenidate in preschool ADHD by Greenhill et al, Jr of the Am Academy of Child and Adol Psychiatry; Nov 2006 3. Pharmacotherapy of the Preschool ADHD Treatment Study (PATS) Children Growing Up’ Vitiello B et al, Jr of the Am Academy of Child &Adol Psychiatry; Jul 2015.