This disorder, which is characterized by poor concentration, impulsivity, and/or hyperactivity, can create difficulties with peers and in multiple settings, such as home and school. ADHD has also been shown to have long-term adverse effects on academic performance, vocational success, and social-emotional development.

The number of children diagnosed with and treated for disruptive disorders, including ADHD, has markedly increased over the last decade. Concurrent with this trend is a growing debate about the best way to prevent, diagnose and treat such problems in children. This is particularly true regarding very young children. A study published in the Journal of the American Medical Association in February 2000 showed that the number of preschool children (ages 2 - 4) receiving stimulants, such as Ritalin, and other psychiatric medications "rose drastically from 1991 to 1995." This study raised concerns because so little is known about the safety and effectiveness of these medications, and because few of these drugs are approved by the U.S. Food and Drug Administration for prescription to young children.

For parents, especially parents of a child who has been diagnosed with a behavioral or emotional disorder or who suspect their child has been suffering from such a problem, concerns about the use of psychotropic medications present serious dilemmas. How should parents make decisions about what course of treatment is the best one for their child?

Importance of Appropriate Assessment and Diagnosis

The first step in successfully treating any mental disorder is an accurate diagnosis. With young children, many factors make proper diagnosis more difficult. Contributing to this difficulty is the lack of access to qualified mental health professionals, and the difficulty obtaining reimbursement for a comprehensive assessment by a qualified professional.

In order to diagnose children with disruptive disorders accurately, health professionals need an understanding both of normal child development and childhood disorders. While all children develop at their own pace, there are developmentally appropriate stages through which children progress. Children in these stages, regardless of their chronological age, exhibit certain behaviors. For example, certain stages of development are characterized by shy behavior, while others are characterized by more motor activity and exploratory behavior.

While teachers, school administrators, or primary care physicians may suggest that a child’s behavior could improve if he/she takes a psychotropic medication, a thorough evaluation and diagnosis by an appropriately trained and credentialed mental health professional should take place before any such decision is made. This will help determine if the child’s behavior is truly outside the normal range and if ADHD is the best diagnosis. For example, a qualified mental health professional could distinguish between ADHD and other disorders, such as anxiety or depression, which may have similar symptoms and behaviors, but call for different treatment approaches. In addition, knowledge and consideration of the social environments in which a child functions-- what the child is experiencing at home and at school-- makes an essential contribution to a more complete understanding of any child and contributes greatly to an accurate diagnosis.

Psychological assessment is an important contribution to any collaborative effort to diagnose and treat childhood behavioral disorders. Psychological assessment provides data to help distinguish between possible alternate diagnoses and improves intervention outcomes by: describing current functioning across a range of environments; confirming or refuting clinical impressions; identifying treatment needs; identifying appropriate interventions; and providing a means of monitoring treatment progress.

Behavioral Treatment as an Important Part of the Treatment Plan

Parents, teachers, physicians, and mental health providers all strive for the same goal: to help the child function at his or her best. It is no surprise that treatment programs, which can take many forms, work best when specifically tailored to the needs of the individual child and when they include a comprehensive approach to services. Such programs may include psychotherapy, such as cognitive-behavior therapy, and/or behavioral management training, parent education, social skills training, and family support service. If it is determined that a child needs medication, it is often most effective when employed in conjunction with behavioral and other interventions.

Recent research supports the use of comprehensive treatment strategies. A 1998 Consensus Development Conference on ADHD sponsored by the National Institutes of Health indicated that stimulant medications, such as Ritalin, can be very helpful over the short-term in treating core clinical symptoms of ADHD. However, the addition of behavioral treatments resulted in improved functioning in areas such as social skills and academic achievement. In December 1999, the NIMH released the results of a large study of elementary school children, ages 7 to 9, which evaluated the safety and relative effectiveness of the leading treatments for ADHD. Conclusions indicated that the use of stimulants alone was more effective than behavioral therapies in controlling the core symptoms of ADHD in attention, hyperactivity/impulsiveness, and aggression. In other areas of functioning, such as anxiety symptoms, academic performance, and social skills, the combination of stimulant use with intensive behavioral therapy was consistently more effective than either treatment alone. In addition, families and teachers reported higher levels of satisfaction for treatments that included behavioral therapy components.

Medical interventions have clearly proven effective for older children and adults who suffer from ADHD. However, not much is known about the long-term effects of stimulants such as Ritalin, and some studies indicate that stimulants have weak and/or unreliable therapeutic effects on many co-occurring emotional and behavioral problems of children with ADHD, such as depression and anxiety disorders. Furthermore, we know little about safety and effectiveness of stimulants for use in children under the age of six, and little about the potential impact of taking psychotropic medication on a child’s developing brain. We also know little about the degree to which gains made while taking medication are sustained after medication usage stops.

Summary and Recommendations

ADHD is a problem of great concern to all of us whether we are policymakers, parents, or mental health care providers. While we know little about the best treatment for very young children with this disorder, we do know a great deal about effective interventions for school-age children with the disorder. We know that proper diagnosis is a critical first step to effective treatment. We know that medication works best when used in conjunction with other interventions, such as behavioral psychotherapy, parent education, and behavioral interventions. We also know that for many children barriers may exist to the best treatments because of lack of access to treatment and because of gaps in our scientific knowledge.

To address the problems of access, several issues are critical to consider. First, families need to be able to access an expert in child behavior who can make a thorough assessment and diagnosis. Once a correct diagnosis of ADHD is made, families need access to the best treatment for their child, including psychotherapy and behavioral interventions. While medical interventions have clearly proven effective for many children, in many cases the use of pharmacological intervention alone is either inappropriate or inadequate. For these reasons, we believe that the best way to diagnose and treat children is through the integrated collaboration of pediatricians, family physicians, psychologists and other health and mental health professionals, parents, and teachers, according to the training, skills and capacities of each and as indicated by a child’s individual needs. Unfortunately, provisions in many health insurance policies hinder families from taking these steps and often force them to make medication their first, and sometimes only, treatment option. Families need better options in helping their children, including health insurance that covers the full array of services research has indicated will help their child.

In addition to addressing the concerns about access to the best treatment, gaps in our knowledge about ADHD must also be addressed. In particular, more research is needed to assess the long-term effects of medication, behavioral therapies, and their combination, on children. Studies of the effect of treatments, including medication, are especially needed for girls and for children under the age of six.

While we need to understand more about the use of psychotropic medications, we also need to understand more about childhood disorders within the context of the family and peers, school, home, and community. This will help us determine how children with different sets of symptoms and needs respond to different types of interventions. The development of early interventions for young children is another area where more research is greatly needed. Finally, further research is needed to help us understand more about how effective interventions may be developed and implemented within various health care settings. NIMH needs additional support to continue to expand research in understanding, treating and preventing children’s mental disorders, and to build a cadre of trained scientists and clinical trials networks to do this crucial research.

Many gaps remain in our response to behavioral and emotional disorders in children. It is increasingly clear that the failure to recognize and treat emotional and behavioral disorders in children and adolescents can have devastating results. We know that untreated mental health problems in childhood are related to substance abuse, juvenile delinquency, suicide, and further problems in adulthood. Developing our knowledge base about childhood disorders, such as ADHD, through investment in research is an investment in the future. Helping children access appropriate, comprehensive mental health services for diagnosis and treatment of ADHD and other disorders is an investment in the life of every child and family who needs help. We can afford to do no less.

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